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What Happens if PTSD is Wiped Away?
PTSD has long plagued veterans. It's also informed our understanding of war’s true terror. Now, as scientists race for a cure, a growing chorus is raising concerns.
As a girl, Simone Emmons dreamed she would carry on her family’s legacy of Army service. A self-described tomboy who grew up with a single mother in rural Maine, Emmons was close to her grandfather, Henry W. Kelly, a decorated World War II veteran who helped liberate the Philippines from Japanese control. Kelly, like most veterans of his era, was proud of his service and rarely spoke of the mental toll it had taken. Instead, his trauma manifested quietly, like when he refused to take Emmons hunting, let alone touch a gun, throughout her childhood.
When Emmons enlisted at 21, she felt that the Army would change her life — and the world — for the better. Yet like her grandfather, she was left with scars that time cannot heal. “I gave the Army my life thinking they’d keep me safe, and that didn’t happen,” she told me. “Now I feel all this apprehension towards people — my doctors, a bank teller, people in authority. I’m trying to protect myself, but it comes off as anger.”
A few weeks into her training at Fort Gordon, Georgia — eager as a new Cub Scout to fit in and make friends —Emmons agreed to take an after-dinner stroll with a man in her unit. He’d seemed nice in the few days she’d known him but turned vicious when the two were alone. As night set in, he treacherously steered her into a remote wooded area, and raped her. Emmons was left in shock but remained dead set on a career in the service. She even continued to train in close quarters with her abuser, though her steely resolve quickly decayed. Emmons went AWOL the weekend after her abuse, holing up in a busted out Red Carpet Inn five miles east of Fort Gordon, hoping to forget what happened. She drank heavily and took whatever drugs she could find. A fellow soldier eventually found Emmons and brought her back inside the fence. But nobody bothered to ask her what was wrong.
A month or two later, after her performance faltered and she’d failed a drug test, Emmons was discharged. On her exit, the Army provided her a plane ticket home, and little else. “I didn’t have a source of income or a place to stay or any education or healthcare benefits,” she said. “All I had was this trauma.” Her next decade became a swirl of self-destructive behavior fueled by suppressed pain. When Emmons achieved sobriety in 2010, she hoped that her problems would be put to rest. But she continued to feel cloudy, off-kilter, angry. In 2015, she visited a mental health counselor at her local Vet Center. She told her story, ticked off her symptoms, and was diagnosed with Post Traumatic Stress Disorder (PTSD) as well as a Traumatic Brain Injury (TBI), which appeared to also stem from her sexual assault.
Emmons is today feeling better thanks to years of therapy, her playful service dog, Gunner, and her supportive husband, Benjamin, who struggles with his own mental anguish from combat tours in Iraq and Afghanistan. Yet PTSD is a notoriously stubborn disease, and Emmons hasn’t fully found peace. She still suffers memory problems and quick, inexplicable mood changes
Desperate to understand what was happening inside her head, Emmons recently turned to the Internet. While scrolling she found a notice from the Department of Veterans Affairs (V.A.) seeking participants for a pioneering project to study PTSD in hopes of finding a cure. As promising as this work sounded, there was a major catch: Emmons couldn’t participate until she was dead. What these researchers wanted was her brain.
As she pondered the idea of donating her brain to the government, Emmons felt the same pure sense of purpose present in her Army days. Perhaps, she hoped, the trauma coded in complex ways across her cerebrum could help untangle the mystery of PTSD for future generations. In short order, she obtained the proper paperwork from the V.A. Then, in a moment reminiscent of her military enlistment, Emmons signed away her brain on a dotted line. “I want to help people down the line, especially women, get a quality of care that I’m not able to get now,” she explained.A single veteran’s brain is highly valuable but exceedingly difficult to acquire. To many, it is the most treasured organ, thought to contain not only the mind, but the soul. Each one holds millions of data points -- a detailed memory bank of birth, battle, the final goodbye, and every moment in between. When one becomes available, researchers have only a few precious hours before its usefulness expires. To ensure speedy recovery and acquisition, the V.A. has established a national network of medical examiners who can respond in an instant any day of the year.
The acquisition process begins inside a hospital or funeral home shortly after a donor’s death. There a brain is harvested, then packed in dry ice and expedited to the cargo bay of the earliest available flight out of town and to the nearest V.A. repository. A special courier awaits the incoming flight and takes the carefully packaged brain to the V.A. facility, where a staffer secures it, slices it into pieces, and freezes it. Psychologists then connect with a donor’s family to obtain biographical data, like service and family health history. This work — and the research made possible by it — represents an unprecedented mobilization to understand and treat one of the oldest, darkest, and most mysterious diseases known to man.
The destructive impact of war trauma was witnessed as early as the Greek Battle of Marathon, but long-term effects were played down for centuries by military leaders on all sides. It wasn’t until veteran activists pressed their case after the Vietnam War that the condition of PTSD was formalized as a diagnosis. In the years since, researchers have developed a slate of evidence-based treatments, but they often prove ineffective for a patient, or only go so far.
It’s not entirely surprising that treatments remain scattershot, to the point of being sometimes crude. While most doctors can get inside the body to study an illness, PTSD was long known only by the verbal descriptions of those who suffered from it. “Nobody knows the pathology of PTSD,” said Dr. Russ Huber, an Army veteran and the director of the V.A.’s brain bank. “Some people get PTSD, and it goes away. Others live with it forever. What we are doing now, which nobody has done before, is studying all parts of the brain with a fine-toothed comb. Our goal is to determine whether PTSD has a brain footprint.”
This work aims to solve a number of neurological mysteries and shift approaches to PTSD diagnosis, treatment and even prevention, for both civilians and service members. If it is successful, treatments may one day smooth the historically tumultuous transition from the military to Main Street. More effective approaches may also shrink the massive veterans’ suicide crisis, which is largely driven by PTSD and has, for many years, claimed some 20 lives a day.
But medical advances are also fueling covert and controversial efforts inside the Department of Defense (DoD) to create “super soldiers” with toned muscles and night vision who require little sleep, feel little pain, and experience little fear. TheDoD and the V.A. have long been at odds, with the former producing wounded warriors that the latter then struggles to make well. Yet in recent years the two agencies have embarked on new collaborations, including this new brain bank. Yet unlike the V.A., which views the brain as an organ to be protected, Pentagon planners see it as a tool to improve lethality, stifle fear on the battlefield, and even wipe away memories of war entirely. As such, burgeoning treatments meant to bring lasting peace will also be weaponized to justify forever wars.
America’s obligation to veterans was solidified in the American imagination by President Abraham Lincoln, who, in the final days of the Civil War, called upon Congress to “care for him who shall have borne the battle and for his widow, and his orphan.” Two major policies stemmed from Lincoln’s request: standardized pension payments and the establishment of a national network of homes for veterans with physical disabilities. Unaddressed were the mental wounds of war, even as they manifested across America in serious and disturbing ways.
In his book, “Shook Over Hell,” Eric T. Dean provides evidence of a widespread mental health crisis among Civil War veterans, including a case study of 291 veterans, most of whom were suicidal and likely suffering from PTSD, who were committed to the Indiana Hospital for the Insane. One of them, a former Union soldier named Owen Flaherty, was transformed by his experiences in the vicious Battle of Stones River such that he long after experienced vivid delusions of Confederate combatants stalking and attacking him.
Trauma was again easily recognizable in the men fighting the battles of World War I. But while military leaders witnessed the terrible toll of trench combat, most treated it as a minor condition that needed to be suppressed. At the height of fighting, soldiers diagnosed with “shell shock” or “cowardice” were ridiculed, court-martialed, and sometimes shot by firing squads. Hundreds were executed by military officers who dismissed the adverse impacts of a violent mission on a soldier’s mind. In his accounting of “The Great War,” journalist Phillip Gibbs documented a wide spectrum of mental illness symptoms suffered by soldiers, from sullen silence to violent convulsions. At one point in the book, a British officer is heard preparing to execute a “swine” who deserted his post during a bombing raid.
As World War I dragged on, and mental disorders debilitated soldiers of all stripes, the U.S. military brought a few psychiatrists to the frontlines, though their orders were clear: improve mission readiness, and fast. This crude form of “forward psychiatry” was short and simple. Oftentimes, it provided nothing more than a few days of food, rest, and encouragement. One of the more holistic treatment regimens was spearheaded by former bayonet instructor Ronald Campbell who, according to Gibbs, “rehumanized [soldiers] by natural means.” Campbell ran a farm for traumatized veterans with vegetables, livestock, and a domesticated bear named Flanagan. “Men who had been dumb, blear-eyed, dejected, shell-shocked wrecks of life were changed quite quickly into bright, cheery fellows, with laughter in their eyes,” Gibbs observed.
Yet this therapy was cut short by military brass, who demanded that their men return to battle. “It's a pity,” Campbell vented. “They have to go off again and be shot to pieces. I cure them only to be killed—but that's not my fault. It's the fault of war.”
A massive influx of American veterans returned home after the first World War, but the U.S. government still had no infrastructure dedicated to their mental healthcare. In a 1922 petition, the Disabled American Veterans (DAV) alleged this neglect had led to “deliberate profiteering” and “inadequate treatment” of mentally disabled veterans. In some shocking cases, veterans in crisis were beaten or killed inside hospitals unprepared for the unique challenges posed.
The DAV petition highlighted dire conditions in Ohio, the home state of then-President Warren G. Harding, and urged him to find$16 million to establish mental health homes for veterans. Harding did not fulfill this request, and is viewed in history as a poor steward of the Veterans Bureau, which was the precursor to the V.A. This reputation was earned after Harding conferred broad budget authority of the Bureau to two corrupt officials who plundered its coffers for their own profit.
This scandal helped advance efforts to consolidate and professionalize veterans care through the July 1930 establishment of the V.A. by an executive order signed by President Herbert Hoover. During its first five years, the V.A.’s work largely consisted of treating a major tuberculosis outbreak. But by the mid-1930s, more than half of the system’s patients suffered serious neuropsychiatric symptoms. This mental health epidemic, like those of the past, went unacknowledged in military circles, likely because accepting the prevalence and power of war trauma would amount to an indictment of conflict itself.
This willful ignorance continued into World War II, when Omar Bradley, the first Chairman of the Joint Chiefs of Staff, issued a memo directing hospital officials to classify psychiatric cases as “exhaustion.” Lieutenant General George S. Patton also denied the phenomenon of mental illness prompted by combat. On at least two occasions, the famously gruff Patton slapped and scolded men who’d sought mental help in field hospitals, behavior for which his boss, General Dwight D. Eisenhower, ordered he apologize. Across the Atlantic, British Prime Minister Winston Churchill ordered his generals to “restrict as much as possible” the exposure of soldiers to psychiatrists.
Many leaders, including psychiatrists, advocated military conflict as a way to develop good character and forge nerves of steel. Even so, psychiatrists were still deployed during World War II to offer help. Some established experimental and potentially dangerous treatments, including one developed by U.S. Air Force psychiatrists in which pilots revisited traumatic memories after being lulled into a trance state by a barbiturate truth serum. The effectiveness of these far-flung treatments is hard to know, since psychiatry was then a burgeoning field and the government did nothing to track the mental health of its soldiers.
After World War II, the V.A.’s first leader, a decorated World War I veteran named Frank Hines, passed the torch to Bradley, who, despite his earlier reluctance to recognize war trauma, transformed the V.A. An organizational mastermind who helped plan D-Day, Bradley quickly established psychiatric services for veterans and launched the agency’s research wing with an emphasis on both physical and mental wounds. Bradley’s historic tenure also cemented the precedent of seasoned military men leading the V.A.
Even as the VA acknowledged war trauma on Bradley’s watch, the department’s mental health offerings for struggling veterans were subpar, even barbaric. According to records hidden deep in the National Archives, the VA lobotomized at least 1,930 World War II veterans who exhibited troubling mental health symptoms after returning home. One was Roman Tritz, a B-17 bomber pilot who died last year. “[The VA] just wanted to ruin my head, it seemed to me,” he told The Wall Street Journal in 2013.
As America crept into the Cold War, the DoD developed (and the V.A. revised) a crude clinical manual of mental disorders, including “gross stress reaction.” When the Vietnam War intensified, the Pentagon stationed an unprecedented number of mental health professionals on the ground. The military also instituted new rules that limited duty tours to one year, a significant change from World War II, when deployments could drag on for years. The military also carved out more time for G.I.s’ rest and relaxation, often out of harm’s way. Follow-up V.A. surveys revealed that, nevertheless, nearly one million veterans suffered from debilitating mental health issues after returning home. Unlike previous generations, many of them also shared their pain. This new candor was, at the time, dismissed by some veterans’ advocates as “whining,” yet it found expression in the peace movement, politics, and culture. For the first time, war trauma became a national problem impossible to ignore.
PTSD was first recognized as a mental health affliction by the American Psychiatric Association in 1980. In 1984, Congress created a Special Committee for Post-Traumatic Stress Disorder to determine what was needed to improve veterans’ mental health care. Its chairman was Dr. Matthew Friedman who, alongside his wife, Gayle Smith, a nurse who served in a Mobile Army Surgical Hospital (MASH) during Vietnam, had begun identifying core PTSD symptoms by interviewing hundreds of recently returned veterans at their rural Vermont home, which abutted a cow field.
Under Friedman’s direction, the committee surveyed 450,000 veterans and drafted recommendations that provided the basis for the V.A.'s clinical approach to PTSD. Friedman then successfully pushed for the 1989 establishment of a National Center for PTSD with a research mission focused on veterans of conflicts past, present, and future.
The center has substantially advanced the world’s understanding and treatment of PTSD. In 1995, for example, researchers first observed in PTSD patients a shrinkage in the hippocampus – the region of the brain that influences memory, learning, and fear.
In the late 1990s, the V.A.’s National Center for PTSD and the Pentagon embarked on their first major joint study that, for the first time, identified biological underpinnings to one of the most valued traits of a warrior: resiliency. This breakthrough came after researchers tracked the neurological activity of special forces put through intensive survival training that included brutal prisoner-of-war simulations. While virtually all of the V.A’s work up until this point concerned treating trauma inflicted by war, this study represented a shift towards research that could be used on the battlefield. Its major takeaway was not around how torture degraded the mental health of servicemembers. Instead, it posited that a molecule called neuropeptide-y could be injected into the brain to create “stress hardy” soldiers.
Results from this study were released four months before the September 11th terrorist attacks, which triggered an explosion of conflict in the Middle East that continues today. As wars erupted, so did the suicide rates among veterans and service members. PTSD also proliferated.
The War on Terror was the first major conflict in which the Pentagon widely assessed servicemembers on mental health metrics before, during, and after their service. This era of conflict also coincided with advancements in gene mapping and neurotechnology that made the V.A.’s PTSD brain bank a feasible venture. It also enabled ongoing Pentagon projects to develop “super soldiers” who can not only fight hard but sleep easy.
Much of this work runs through the Defense Advanced Research Projects Agency (DARPA), a secretive wing of the military industrial complex whose unofficial motto is “change what’s possible.” In 2014, DARPA established its Biological Technologies office, which aims to augment warriors through synthetic forms of evolution and adaptation. The brain bank was first funded that same year with a similar mandate of better understanding, and possibly preventing, the natural reaction to war.
The impetus behind the bank’s creation came from Dr. Robert Ursano, Chair of Psychiatry at the DoD’s Uniformed Services University of Health Sciences (USUHS). In 1999, USUHS was gifted 300 brains to empower research into schizophrenia and bipolar disorder. In the early aughts, Ursano enlisted Friedman in work to create a similar repository focused on PTSD. In 2014, after years of hard work, the two secured $3 million from Congress to establish the bank, which now receives a $10 million annual appropriation .
Today, V.A. and affiliated academic institutions collect and study the brains at sites across the country while USUHS officials stitch together post-mortem assessments of donors’ work, life, and trauma history. “PTSD is not a problem of remembering; it's actually a forgetting disorder,” Ursano said. Asked about what potential insights he’s seeking through the brain bank, Ursano said he hopes to discover why PTSD creates “an impairment in the ability to forget.” He would like to fix that.
The brain bank’s largest hub is located in a nondescript, one-story white building on the outskirts of the V.A.’s Boston campus, in the quiet residential neighborhood of Jamaica Plain. There are few windows in the building, which holds lab equipment, medical-grade knives, and large white freezers holding tissue from across the country. In the corner of the main dissection room sits a series of large glass jars filled with whole brains floating in a clear, viscous liquid.
The bank is overseen by Dr. Huber, whose passion for neuropathology stemmed from a singular experience at Fort Stewart, Georgia near the tail end of the Gulf War. It was there that he encountered a fellow soldier plagued by a series of puzzling and debilitating neurodegenerative symptoms later diagnosed as Gulf War Syndrome. Nearly three decades later, researchers are still working to understand the condition’s root causes, though they have uncovered evidence that brain trauma may contribute to its formation.
Huber’s work unraveling the mysteries of PTSD today consumes much of his life. He’s often called in to slice tissue on weekends, holidays, and at strange hours, when a fresh brain arrives. “My family has grown accustomed to that fact that sometimes I’ll disappear to take care of a brain,” he said, adding that the urgent nature of this work ensures valuable genetic data does not expire.
Once a brain is harvested, Huber and his colleagues study deli-slice thin parts of tissue under a series of fluorescent microscopes, including one valued at nearly $1 million that can venture deep into brain cells. Through this lens, the brain resembles a dark sky dotted with brilliant constellations – an infinite space of data that may provide clues on how the brain internalizes trauma. “Your brain defines who you are,” said Huber. “It’s your identity. It’s more complex than the most advanced computer; it’s an amazing galaxy of cells. Who wouldn’t want to become an astronomer in this mysterious land?”
During the fall of 2015, the first research to come out of the brain bank revolutionized our understanding of PTSD by identifying a specific gene associated with its development. This breakthrough has enabled researchers to chart a rough path for therapeutic boosting of this gene which, in turn, could build resilience to neurotrauma.
More recent brain bank work has identified inflammation as another factor that may play into the formation of PTSD and identified genetic overlaps between it and other mental conditions, including schizophrenia and bipolar disorder. Another paper identified unique physiological markers in the brains of veterans with PTSD who committed suicide. Ongoing research aims to understand whether trauma manifests differently in men and women, and how it may even vary according to specific conflicts and various social and environmental factors.
Huber, Friedman, and other PTSD pioneers are working diligently to ensure these insights are used to morally mitigate mental damage. They believe that the Pentagon shares their mission and could, for instance, one day deny enlistment to those identified as having distinct genetic markers that put them at particular risk for developing PTSD when exposed to violence. Yet this optimistic thinking belies a long history of military brass subverting health concerns in favor of the mission. The DoD, for instance, adopted a strict screening process at the beginning of World War II that denied service to 740,000 recruits on neuropsychiatric grounds. Yet they abandoned these measures as manpower needs increased. “The people I work with in DoD share my commitment to good and ethical science,” Friedman said. “But DoD is a big place.”
DARPA is housed four miles west of the sprawling Pentagon complex, in a sleek glass building that local police have tried to prevent from being photographed. The agency was founded as an anxious response to the 1957 Sputnik satellite launch. Its chartered mission was to ensure “technological superiority” across the American military spectrum.
Over the last 60 years, DARPA’s largely met this goal through a flurry of cutting-edge developments, from satellites to flamethrowers. Today, much of their work concerns the less tangible work of identifying mental trauma, and fixing it. In service of this operation, the agency brought in the V.A.’s PTSD experts to help create predictive tools that identify veterans in mental crisis. In 2015, the V.A. adopted one of DARPA’s tools, a Big Brother-style phone application called Cogito that analyzes veterans’ online behavior and records their voices to determine their mental health and risk of suicide.
Most troubling aren’t DARPA’s diagnostic tools, but their curative ones. The agency’s now researching fast-acting, long-lasting pharmacological treatments intended to not only treat symptoms of mental illness, but also wipe away their underlying neurochemical roots. Officials are also building neuro-chips intended to heal service members’ physical and mental trauma. This work is being stood up through the Systems-Based Neurotechnology for Emerging Therapies (SUBNETS), a program in which chips record key neural pathways in normal and damaged subjects in hopes of replicating normal functionality and reverting damaged brains to a pre-trauma state. Another DARPA project known as Restoring Active Memory (RAM) aims to prevent forgetting among servicemembers with TBIs through an implantable device that can essentially hack and rewrite neurons, which code major memories.
These technologies may one day help soldiers heal but could also sanitize war in troubling ways. Had they existed during the Greek Battle of Marathon, for instance, Herodotus may have never witnessed and written about an Athenian gone blind after watching a comrade die. Were soldiers in World War II provided these treatments, Kurt Vonnegut may never have penned “Slaughterhouse Five,” his darkly comical polemic about prisoners of war and the bombing of Dresden. For generations, these sorts of blunt, brutal war stories have informed mankind’s understanding of conflict, and created an aversion to it. Retired Air Force Major General Robert Latiff put it this way: “Do you want soldiers who come home from a war and don’t remember how awful it is?”
“I think just the opposite; you want soldiers to experience the horrors of war,” Latiff said. “That may sound cruel or counterintuitive coming from a military person. But from an ethical standpoint, you don’t want to make war a walk in the park. You don’t want to make it easy.”
While DARPA developers kept these issues front-of-mind by consulting with an independent panel of ethical, legal, and social scholars, two panelists said they haven’t been contacted by the agency for nearly a year. One of them, Dr. Steven Hyman, said that, in addition to DARPA’s work, a number of other emerging PTSD therapies also raise ethical questions, including a beta-blocker called propranolol, which makes it possible to alter memories, and Ketamine, which has been found to extinguish them altogether.
“It is possible that we may one day be stupendous at brainwashing; that is replacing adverse and intrusive memories with benign ones,” said Hyman, who directs the Stanley Center for Psychiatric Research at MIT and Harvard. “We might in that sense ‘cure’ PTSD, but we may also cure the conscience.”
Last year, the Food and Drug Administration cleared the way for human testing of a DARPA-backed neuro prosthetic that stimulates the vagus nerve, which transports sensory messages to and from the brain. There’s hope this stimulation could triple the effectiveness of PTSD talk therapies, though some worry that the stimulation could potentially exacerbate symptoms. Dr. Mike Kilgard, an expert in neural plasticity who is spearheading this project, admitted that outstanding questions remain over the device’s efficacy and safety. But he said he hoped it would one day make it easier for the horrors of war to be communicated to the public.
“One should worry over anything that makes it easier to fight or creates a lower burden to begin a war,” he said. “My hope is that with this chip, the opposite would occur. Imagine a veteran who remembers everything but doesn’t wake up with the sweats. Someone who is happy to share their story without their heart pounding out of their chest.”
Due to her history of addiction, Emmons has refused the available cocktail of pain prescriptions, and is today treating her trauma only through natural means. Her self-described “bag of tricks” includes therapy, yoga, and meditation. Yet it’s been giving of herself that’s proved most therapeutic.
This sort of self-sacrifice, of putting all before one, is an enduring theme in military dogma, and one Emmons remains steadfastly committed to. It’s this selflessness that helps explain her willingness to risk her life for this country, and also pledge her brain to it. Emmons spends much of her time these days as a healer, be it in her work as a masseuse or through her non-profit, which pairs service dogs with survivors of sexual abuse.
Even after all the head and heart ache that the Army forced on her, Emmons said she’d re-enlist “in a heartbeat” were she younger and not raising three kids. For her, any ethical concerns over ongoing PTSD research pales in comparison to the idea of a magical, restorative pill or product that could enable her and her husband to rejoin the ranks. “To be able to fight for America and not be mentally damaged by it?” she said. “I support that.”