Examples of Cases Treated

(Most clinical material comes from a compilation of cases treated or is otherwise disguised. Any correlation is simply coincidental.)

While down-range, I treated everything from first-break psychosis, to depression, to PTSD, to substance intoxication, and beyond. I also had a chance to meet less typical psychiatric cases. For example, there was one very stoic infantry Soldier Sergeant who happened to come in one afternoon. He was quite sheepish, showing up to the mental health building—not something an infantryman does often. He sat and described sudden paroxysms of racing heart and breath (he had already seen primary care already with normal EKG).

He was describing a typical, and quite ordinary new onset panic disorder. But I think it was the humility and simpleness of his request (from a psychiatric perspective, not at all from his perspective) that got me. It was a highlight of my time to shepherd this proud man, who did not until then believe in mental health, to being panic-free, via an SSRI and basic psychotherapy. It helped him weather the time of going back to the Infantry living area, and participating in wrestling, weight lifting, and other things that these seemingly uninitiated into any mental health did to pass the time.

A bit more extreme, but unfortunately another typical experience in general psychiatry, is first break psychosis. One episode happened one early evening when I was called by radio (our downrange equivalent of, what we would have here, CONUS, a pager, or cell phone) to see a young Soldier brought in by his friend. The reason for coming in was apparently strange behavior. He believed his video games were talking to him, specifically, and that he was being called by God, through crop circles on YouTube, to solve mankind’s problems by converting everyone to vegetarianism. In addition to the psychiatric management of the psychosis, this story highlights the 24-7-365 nature of deployment for a psychiatrist. It is true that technicians and social workers and others can assist in many things; but, in complex situations, needing admission or evacuation, such as psychosis, there needs to be a psychiatrist—and, in this case, like most downrange, there is only one psychiatrist.

In another case, I treated a soldier who felt that he was in severe danger, despite that fact that during my deployment on the COB was generally safe. It is true there was a rare rocket attack or mortar, and even rarer landing in the LSA (living support area), but it was rare enough to be believed safe by many there. Notably, I do find myself minimizing the exposure, probably as a grandiose defense against my own annihilation.

Additionally, his intelligence on military entrance exams was on the lower range, which might explain the limited ability to integrate a more realistic appraisal of the threat into his own experience. This patient presented mainly with problems of concentration problems, which responded well to regular supportive psychotherapy. For him, somehow the regularity of the containing and holding functions for his affects in the therapy allowed him to continue his mission.

I also treated a case of PTSD, presenting as depression, from rape. She had been a younger Soldier who was “taken under the wing” of a more senior NCO. They would spend some evenings studying for the “board,” a demanding oral exam of military regulations and culture, which the younger soldiers have to pass this in order to advance. It was in that context one night that they were studying that the rape occurred. It was an assault in the purest sense—there was no ambiguity. She was held down, and he forced himself upon her. The patient did not want to tell authorities at that time or when I saw her, which was a little over a year from the event, due to concerns about stigma and that her unit might ostracize her. Additionally, reporting requirements in the military regulations were less clear at the time, so I maintained her wishes that the event remain in the confidences of the doctor-patient relationship with me. Notably, she was withdrawn, her affect was not very interactive in session, and she was clearly in a low energy, depressed state. I prescribed medications, and there was some benefit, but she otherwise remained symptomatic.

Despite her symptoms, she had always remained very functional in her job and her military command—she had since PCS’d, so it was different from the unit in which the rape occurred—had no idea that she was getting care for depression. This vignette illustrates the challenges of treating non-combat trauma in a combat zone, and how destructive military sexual trauma is to the force, despite the resilience and dedication of those who have experienced it.

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