Archive for the ‘Uncategorized’ Category

ANNIE HAMILTON

XXXX Avenue

Ventura, CA 93004

805-323-5027 (home office)

805-612-9039 (cell phone)

Annie.Hamilton@gmail.com

CURRICULUM VITAE

Motivated Writer/Researcher offering a decade of professional and personal expertise in a variety of areas. 

RELEVANT SKILLS ASSESSMENT

 

*Research (internet/manual)

*Unique ability to take complicated terms and adapt to a wider, consumer-based audience

*Proposal development

*Exceptional turnaround

*Manual development

*Technical writing

*Textbook development

*Develop original content that is ‘viral-worthy’ (the type of material that people will share with their friends via *Facebook, twitter, linked-in, myspace, email and other social networking sites)

*Repurposing partner content, translating into highly usable Q & A format designed to captivate audience with ‘wow’ factor.

*Exceptional communication techniques for maintenance of both internal and external ‘flow factor’ (and projects    are always on time)

*Have been researching medical conditions since the 80’s both personally and professionally

*Extensive experience as a Published Writer, Editor, Patient Advocate, Physicians Advocate, Outreach Coordinator and Patient Counselor. Throughout each endeavor I’ve maintained my research and writing initiatives.

 

FEATURED RELEVANT PROJECTS

*I co-wrote a chapter for the 4th edition of the Pituitary Patient Resource Guide (also translated into multiple languages, taught in medical schools and sold in book stores) link to chapter here:

http://www.amazon.com/Pituitary-Patient-Resource-Guide-Revised/dp/0966014111

My chapter deals with hormonal dysfunction, diagnosis, finding a good physician, being your own advocate, seeking treatment, working with your HR department, emotional, insurance and financial issues and end of life care.

The rest of the guide features contributions by physicians and other writers (like me) including Bram Levy, Sharmyn McGraw, Shereen Ezzat MD (University of Toronto) Edward Laws MD, University of Virginia, George Chrousos MD, National Institutes of Health and University of Athens, Dan Kelly MD, UCLA and too many others to list. It’s an excellent resource, written in easy to understand language outlining issues such as menopause, dealing with insurance carriers, sexual dysfunction, Thyroid disease, Pituitary tumors and various other health ailments that are often underdiagnosed but can lead to deadly problems later in life when missed.

*In ’04 My Organization assembled a conference to discuss Hormonal Health (with the hopes of raising awareness through the Federal Government) and held the sessions at the NIH, including the NIMH, Naval Academy, Office of Research on Women’s Health (Dr. Vivian Pinn) Swedish Neuroscience in Seattle, UCLA, Cleveland Clinic, University of Toronto, John Hopkins, Stanford’s Pituitary Center, UCSF, Mass General/Harvard, Chicago Institute of Neurosurgery (link to program below)

http://media.pituitary.org/pdf/PituitaryFactSheet.pdf

*2004 Patient outreach conference in Chicago (my role was to hold Q & A sessions with patients and address concerns relating to hormonal health, menopause, thyroid disease and post-operative care.)

 Hosted by Dr. Gail Rosseau (candidate for U.S. Surgeon General in 2009)

Gail Rosseau MD, Director of the Cranial Base Surgery

Chicago Institute of Neurosurgery and Neuroresearch

*2004 Patient & Physician outreach conference in Orlando (my role was the same as above except I also developed the materials for the sessions)

Hosted by Dr. Marc Mayberg (Director of Seattle Neuroscience Institute) and Dr. Larry Katznelson (co-Director of Stanford Pituitary Center and attended by most of the same people)

*2005 Hormonal impact on psychosocial dysfunction (again, role was the same similar with increased responsibilities, including directing the research, developing the marketing materials, writing the program and hosting the committee)

Hosted by Dr. Shereen Ezzat (University of Toronto) and Robert Knutzen MBA in San Diego

*THE HUMAN ENDURANCE PROJECT 2010-ongoing

Submitted to the Rolex committee for 2012 consideration

http://www.human-endurance.org/

SCIENTIFIC RESEARCH* PTSD, ‘HORMONAL IMPACT ON PSYCHOSOCIAL DYSFUNCTION

COLONEL ANDREW P. O’MEARA, ANNIE HAMILTON, LEAD MEDICAL WRITER/DIRECTOR OF RESEARCH

LT. GENERAL THOMAS MCINERNEY, LINDA RIO, PSYCHOTHERAPIST, GERALD BOCK, MD, TRAUMA SURGEON,

BRIGADIER GENERAL WILLIAM MULLEN, GEORGE CHROUSOS MD, NIH, UNIVERSITY OF ATHENS

Endeavoring to reduce the diagnostic time between onset of symptoms and life interruption

ACE CURRICULUM PROGRAM – JULY 2010 – ongoing

Curriculum Writer/Developer – Writing modules for Universities, editing textbooks/proofreading specialty projects, all of which must be approved through state boards, agencies, etc. Subjects including: tax law, banking, annuities, health insurance, disability, legal matters, accounting, ethics, history, cultural affairs and a variety of other topics.

PITUITARY NETWORK ASSOCIATION

Director of Medical Affairs/Patient Advocacy

(Patient & Physician organization dedicated to the research and development of knowledge related to neuroendocrine disorders, pituitary tumors and female health dysfunction)

Responsible for development & distribution of educational resources, (gathering research and data, writing papers, writing press releases and letters, writing chapters for journals and texts, articles for websites, patient communications, physician communications, prep work for national conferences (two samples attached, one is for a national conference I assembled research and   circulated updates to neuroendocrinologists and neurosurgeons throughout the world and connected patients to surgeons for care, counseled patients, developed and chaired workshops, lectures, conferences, fundraising/grant writing, committee participation, chairing and management.

CARROLL INSURANCE GROUP, J. PATRICK CARROLL, PRESIDENT

2005-2007

Technical writing projects and corporate branding

OTHER INSTITUTIONS WORKED WITH INCLUDE; NIH,NIMH, Veteran’s Administration, Physicians Associations, Washington State Baseball Association, Pituitary Network Association, Big League Edge, Tucker Sherman Project, California Lutheran University, Swedish Neuroscience, US Naval Medical Center, University of Athens, Huwaldt Insurance, Office of Research on Women’s Health, American Brain Tumor Association, Prevent Youth Smoking American Lung

My educational background has exclusively focused on Research, Science and Music (PLU and Julliard) but not Writing although my experience is multi-faceted and more than a decade.

 

My Paper, “The Tucker Sherman Project” was nominated for the Rolex award in 2003 and received accolades and critical review from dozens of professionals.

Stress and Disorders of the Stress System

George P. Chrousos

Posted: 07/21/2009; Nat Rev Endocrinol. 2009;5(7):374-381. © 2009 Nature Publishing Group

Abstract and Introduction

Abstract

All organisms must maintain a complex dynamic equilibrium, or homeostasis, which is constantly challenged by internal or external adverse forces termed stressors. Stress occurs when homeostasis is threatened or perceived to be so; homeostasis is re-established by various physiological and behavioral adaptive responses. Neuroendocrine hormones have major roles in the regulation of both basal homeostasis and responses to threats, and are involved in the pathogenesis of diseases characterized by dyshomeostasis or cacostasis. The stress response is mediated by the stress system, partly located in the central nervous system and partly in peripheral organs. The central, greatly interconnected effectors of this system include the hypothalamic hormones arginine vasopressin, corticotropin-releasing hormone and pro-opiomelanocortin-derived peptides, and the locus ceruleus and autonomic norepinephrine centers in the brainstem. Targets of these effectors include the executive and/or cognitive, reward and fear systems, the wake–sleep centers of the brain, the growth, reproductive and thyroid hormone axes, and the gastrointestinal, cardiorespiratory, metabolic, and immune systems. Optimal basal activity and responsiveness of the stress system is essential for a sense of well-being, successful performance of tasks, and appropriate social interactions. By contrast, excessive or inadequate basal activity and responsiveness of this system might impair development, growth and body composition, and lead to a host of behavioral and somatic pathological conditions.

Introduction

“Hypothalamic hypophysiotropic factors” were originally proposed by G. W. Harris in the 1940s; since then, a substantial body of evidence has confirmed that these factors do indeed exist.[1-3] The survival of complex organisms—at both the individual and species levels—relies on these factors, which include mediators that regulate homeostasis and influence behavior, energy metabolism, growth, reproduction and immunity. This Review provides a brief, albeit comprehensive, synthesis of information on the conceptual evolution, technological advances and current understanding of homeostasis and stress, and describes the salutogenic changes or pathogenic disturbances that are associated with eustress or distress, respectively. This article is divided into three parts: the first discusses the concepts related to homeostasis and stress, the second details the mediators and mechanisms of the stress response, and the third describes the effects of stress on an organism.

Concepts of Homeostasis and Stress

All living organisms maintain a complex dynamic equilibrium, or homeostasis, which is constantly challenged by internal or external adverse effects, termed stressors.[4,5] Thus, stress is defined as a state in which homeostasis is actually threatened or perceived to be so; homeostasis is re-established by a complex repertoire of behavioral and physiological adaptive responses of the organism. The development of concepts of homeostasis and stress is summarized in Box 1 .

Box 1 History of stress

The term stress originates from the Indo–European root ‘str’, which has been historically associated with exertion of pressure. Thus, both the Greek ‘strangalizein’ and its English derivative and synonym ‘to strangle’, as well as the Latin ‘strigere’ (to tighten), have their origins in the very distant past. The concept of homeostasis as the general principle of balance or equilibrium of life was first enunciated clearly by the ancient Greek natural philosophers, who called it ‘harmony’ (Pythagoras) or ‘isonomia’ (Alkmaeon).[4,75] The modern synonym ‘homeostasis’, which means steady state, was coined by the American physiologist walter Cannon in the beginning of the 20th century, whereas the word ‘stress’ was first used with its current meaning and popularized by the Hungarian Canadian experimentalist Hans selye a few decades later. Both Cannon and selye employed Hooke’s law of elasticity to heuristically and creatively extrapolate physical concepts into biology.[76–81]

Stressors comprise a long list of potentially adverse forces, which can be emotional or physical. Both the magnitude and chronicity of stressors are important. When any stressor exceeds a certain severity or temporal threshold, the adaptive homeostatic systems of the organism activate compensatory responses that functionally correspond to the stressor. The stress system has a major role in coordination of this process ( Box 2 ).[2,3] The stress syndrome is a relatively stereotypic, innate response that has evolved to co-ordinate homeostasis and protect the organism during acute stress. Changes take place in the central nervous system (CNS) and in various peripheral organs and tissues. In the CNS, the stress response includes facilitation of neural pathways that subserve acute, time-limited adaptive functions, such as arousal, vigilance and focused attention, and inhibition of neural pathways that subserve acutely nonadaptive functions, such as eating, growth and reproduction. In addition, stress-related changes lead to increased oxygenation and nutrition of the brain, heart and skeletal muscles, which are all organs crucial to the central coordination of the stress response and the ‘fight or flight’ reaction.

Box 2 Central and peripheral functions of the stress response2

Functions of the central nervous system

  • Facilitation of arousal, alertness, vigilance, cognition, attention and aggression
  • Inhibition of vegetative functions (e.g. reproduction, feeding, growth)
  • Activation of counter-regulatory feedback loops

Peripheral functions

  • Increase of oxygenation
  • Nutrition of brain, heart and skeletal muscles
  • Increase of cardiovascular tone and respiration
  • Increase of metabolism (catabolism, inhibition of reproduction and growth)
  • Increase of detoxification of metabolic products and foreign substances
  • Activation of counter-regulatory feedback loops (includes immunosuppression)

Homeostatic mechanisms, including the stress system, exert their effects in an inverted U-shaped dose–response curve (Figure 1). Basal, healthy homeostasis (or eustasis) is achieved in the central, optimal range of the curve. Suboptimal effects may occur on either side of the curve and can lead to insufficient adaptation, a state that has been called allostasis (different homeostasis) or, more correctly, cacostasis (defective homeostasis, dyshomeostasis, distress), which might be harmful for the organism in the short term and/or long term.[2,3] Both hypofunction and hyperfunction of the homeostatic systems of the organism have multiple adverse effects. For instance, both defective and excessive reactions to fear entail a decreased ability to survive of the individual and the species. Thus, both fearless, uninhibited individuals and fearful, excessively inhibited individuals have increased risks of morbidity and mortality, the former as a result of underestimating danger, the latter as a result of decreased social integration.

Figure 1  Homeostatic systems exert their effects in an inverse, U-type dose response.[2] Eustasis is in the middle, optimal range of the curve. Suboptimal effects may be on either side of the curve and can lead to suboptimal adaptation, termed allostasis or, more correctly, cacostasis, which may be harmful for the organism in the short term or long term.

 

Eustasis is in the middle, optimal range of the curve. Suboptimal effects may be on either side of the curve and can lead to suboptimal adaptation, termed allostasis or, more correctly, cacostasis, which may be harmful for the organism in the short term or long term.

The interaction between homeostasis-disturbing stressors and stressor-activated adaptive responses of the organism can have three potential outcomes. First, the match may be perfect and the organism returns to its basal homeostasis or eustasis; second, the adaptive response may be inappropriate (for example, inadequate, excessive and/or prolonged) and the organism falls into cacostasis; and, third, the match may be perfect and the organism gains from the experience and a new, improved homeostatic capacity is attained, for which I propose the term ‘hyperstasis’.

Mediators of Homeostasis and Stress

Stress mediators, which include the classic neuroendocrine hormones of the stress system, but also several other neurotransmitters, cytokines and growth factors, regulate both basal and threatened homeostasis and might mediate the pathogenesis of dyshomeostasis-related diseases.[2,6-8] Pivotal to our understanding of these mediators and their effects on the human organism in health and disease has been the above-mentioned concept of hypothalamic hypophysiotropic factors.

Central and Peripheral Effectors

The principal, greatly interconnected CNS effectors of the stress system, include the hypothalamic hormones arginine vasopressin (AVP), corticotropin-releasing hormone (CRH), the pro-opiomelanocortin-derived peptides a-melanocyte-stimulating hormone and ß-endorphin, and norepinephrine produced in the A1/A2 centers of the brainstem’s locus ceruleus and in the central, autonomic nervous system.[2,3] Of note, other ascending aminergic pathways, such as the serotonergic pathways that originate from the midbrain (nuclei raphe) and the posterior hypothalamic histaminergic systems, accompany the locus ceruleus-derived norepinephrine central stress response through secretion of 5-hydroxytryptamine and histamine, respectively.

The principal peripheral effectors are glucocorticoids, which are regulated by the hypothalamic–pituitary–adrenal axis, and the catecholamines norepinephrine and epinephrine, which are regulated by the systemic and adrenomedullary sympathetic nervous systems. Interestingly, postganglionic sympathetic nerve fibers also secrete CRH, among other substances, whereas both catecholamines stimulate interleukin (IL-) 6 release by immune cells and other peripheral cells via ß-adrenergic receptors.[8-10] The targets of all these stress mediators include the executive and/or cognitive, the fear/anger and reward systems, the wake–sleep centers of the brain, the growth, reproductive and thyroid-hormone axes, as well as the gastrointestinal, cardiorespiratory, metabolic, and immune systems.

The Roles of Corticotropin-releasing Hormone

Shortly after isolation and sequencing of the 41 amino acid CRH in the mid-1980s,[11] researchers showed that when this neuropeptide, which does not cross the blood–brain barrier, was injected into the cerebral ventricles of experimental animals, it could reproduce the stress response summarized in Box 2 .[2,7,12] A series of subsequent studies showed that the hypothalamic CRH–AVP and brainstem norepinephrine centers of the stress system mutually innervate and stimulate each other.[2,7,12] This mutually reinforcing positive-feedback system could, therefore, be activated by CRH, norepinephrine or any other stimulus that could set into motion either side of this highly complex, but integrated, brain loop.

Box 2 Central and peripheral functions of the stress response2

Functions of the central nervous system

  • Facilitation of arousal, alertness, vigilance, cognition, attention and aggression
  • Inhibition of vegetative functions (e.g. reproduction, feeding, growth)
  • Activation of counter-regulatory feedback loops

Peripheral functions

  • Increase of oxygenation
  • Nutrition of brain, heart and skeletal muscles
  • Increase of cardiovascular tone and respiration
  • Increase of metabolism (catabolism, inhibition of reproduction and growth)
  • Increase of detoxification of metabolic products and foreign substances
  • Activation of counter-regulatory feedback loops (includes immunosuppression)

The stress system interacts with, influences and is influenced by several systems in the brain that serve cognitive and/or executive, fear and anger and reward functions; these systems form a complex, integrated, positive and negative feedback-system loop.[2,7,12-20] Furthermore, the stress system acutely and in a temporally limited fashion activates the central nucleus of the amygdala, which has its own CRH system involved in the generation of fear and/or anger; in return, the central nucleus of the amygdala stimulates the stress system and forms a mutually reinforcing positive-feedback loop.[13,14] This system also activates (acutely and transiently) the mesolimbic, dopaminergic reward system (which links the ventral tegmental area to the nucleus accumbens) and the mesocortical, dopaminergic system (which links the ventral tegmentum to the frontal–prefrontal lobe), whereas it receives inhibitory input from the latter.[16-19] Finally, the stress system acutely activates the hippocampus—an organ that has a major role in intermediate-term memory—whereas it receives negative input, partly as negative feedback from the circulating glucocorticoids of the hypothalamic–pituitary–adrenal axis to its hypothalamic center, the paraventricular nucleus, and partly as tonic, hippocampal inhibitory input upon the stress system.[20]

Arousal and Sleep

Activation of the stress system stimulates arousal and suppresses sleep;[12] conversely, loss of sleep is associated with inhibition of the stress system. Interestingly, sleep loss is also associated with elevated level of circulating IL-6 in spite of the reduced stimulatory effect of catecholamines on IL-6 secretion; this change possibly results from the concurrently decreased cortisol-mediated inhibition.[21-26]

Metabolism

During acute stress, the heart rate and arterial blood pressure are increased, while gluconeogenesis, glycogenolysis, lipolysis and hepatic glucose secretion are stimulated, owing to elevated levels of catecholamines and cortisol ( Box 2 ).

Box 2 Central and peripheral functions of the stress response2

Functions of the central nervous system

  • Facilitation of arousal, alertness, vigilance, cognition, attention and aggression
  • Inhibition of vegetative functions (e.g. reproduction, feeding, growth)
  • Activation of counter-regulatory feedback loops

Peripheral functions

  • Increase of oxygenation
  • Nutrition of brain, heart and skeletal muscles
  • Increase of cardiovascular tone and respiration
  • Increase of metabolism (catabolism, inhibition of reproduction and growth)
  • Increase of detoxification of metabolic products and foreign substances
  • Activation of counter-regulatory feedback loops (includes immunosuppression)

Growth, Reproduction and Thyroid Function

The growth, reproductive and thyroid-hormone axes are inhibited at several levels by stress mediators, whereas estradiol and thyroid hormones stimulate the stress system.[2,7,12,27]

Gastrointestinal Function

During stress, the gastrointestinal system is inhibited at the level of the stomach via the vagus nerve, while being stimulated at the level of the large bowel via the sacral parasympathetic system, which is activated by brainstem-derived norepinephrine.[12,28]

The Immune System

Stress has complex effects on the immune system and influences both innate and acquired immunity.[6,8,9,29-31] Glucocorticoids and catecholamines influence trafficking and/or function of leukocytes and accessory immune cells and suppress the secretion of proinflammatory cytokines (tumor necrosis factor [TNF], IL-1, IL-6, IL-8 and IL-12), whereas both hormone families induce a systemic switch from a TH1 response (that is, cellular immunity) to a TH2 response (humoral immunity). Conversely, proinflammatory cytokines stimulate the stress system, also at multiple levels, in both the CNS and peripheral nervous system, including the hypothalamus, central noradrenergic system, pituitary and adrenal glands, which increases glucocorticoid levels and consequently suppresses the inflammatory reaction. These actions form another important negative-feedback loop that protects the organism from overshoot of the inflammatory response.

Peripheral secretion of ‘authentic’ CRH (originally described as ‘immune’ CRH because of its inflammatory actions) by postganglionic sympathetic neurons and norepinephrine-activated release of IL-6 by peripheral immune cells and other cells, respectively, lead to degranulation of mast cells (that is, the release of inflammatory and vasoactive molecules from their secretory vesicles) in several tissues and activates the sickness syndrome.[6,8,9,31-33] The former action represents an important component of the neurogenic inflammatory response, whereas the sickness syndrome results from innate processes of the organism that are triggered and sustained by a systemic, inflammatory reaction. The syndrome includes somnolence, fatigue, nausea and depressive mood; these symptoms occur concurrently with activation of the acute-phase reaction by the liver and stimulation of the sensory-afferent nervous system, which manifests as hyperalgesia and fatigue.

Cortisol is a greatly pleiotropic hormone that influences up to 20% of the expressed human genes and affects all major homeostatic systems of the body, including innate and acquired immunity.[34-36] Of great interest are the mutual interactions of the multiple isoforms of the activated glucocorticoid receptor with several transcription factors, such as AP-1, COUP-TF1, NF?B, and the STATs, through which various brain functions, growth, immunity and metabolism are regulated in a coordinated and highly stochastic fashion.[34-36]

Stress-system Disorders

The stress system has a basal circadian activity and also responds to stressors on demand.[2-5] Appropriate basal activity, as well as quantitatively and temporally tailored responsiveness of the stress system to stressors, is essential for a sense of well-being, adequate performance of tasks and positive social interactions. On the other hand, inappropriate basal activity and/or responsiveness of the stress system, in terms of both magnitude and duration, might impair growth, development and body composition, and might account for many behavioral, endocrine, metabolic, cardiovascular, autoimmune, and allergic disorders. The development and severity of these conditions depend on the genetic, epigenetic and constitutional vulnerability or resilience of the individual to stress, their exposure to stressors during ‘critical periods’ of development, the presence of concurrent adverse or protective environmental factors, and the timing, magnitude and duration of stress.

Prenatal development, infancy, childhood and adolescence are times of increased vulnerability to stressors. The presence of stressors during these critical periods can have prolonged effects, such as sustained cacostasis that can last the entire lifetime of an individual. These effects are determined constitutionally and/or epigenetically and are (to a large extent) mediated by stress hormones, such as CRH and cortisol, that have profound effects on the brain’s stress response (Figure 2).[2,37-40] Naturally, during these same critical periods, individuals are similarly sensitive to propitious environments, which induce hyperstasis and lead to the development of resistance to stressors in adulthood.

Figure 2  Chronic stress can lead to development of the metabolic syndrome.35

 

Abbreviations: ABP, arterial blood pressure; ACTH, adrenocorticotropic hormone; APR, acute-phase reactants; AVP, arginine vasopressin; CRH, corticotropin-releasing hormone; iCRH, immune CRH; E, epinephrine; E2, estradiol; GH, growth hormone; HPA, hypothalamic-pituitary-adrenal; IGF-I, insulin-like growth factor I; IL-6, interleukin 6; LC, locus ceruleus; LH, luteinizing hormone; NE, norepinephrine; T, testosterone; TG, triglycerides.

Acute and Chronic Stress-related Diseases

Through its mediators, stress can lead to acute or chronic pathological, physical and mental conditions in individuals with a vulnerable genetic, constitutional and/or epigenetic background.[3-10,20,36] Acute stress may trigger allergic manifestations, such as asthma, eczema or urticaria, angiokinetic phenomena, such as migraines, hypertensive or hypotensive attacks, different types of pain (such as headaches, abdominal, pelvic and low-back pain), gastrointestinal symptoms (pain, indigestion, diarrhea, constipation), as well as panic attacks and psychotic episodes. Chronic stress may cause physical, behavioral and/or neuropsychiatric manifestations: anxiety, depression, executive and/or cognitive dysfunction; cardiovascular phenomena, such as hypertension; metabolic disorders, such as obesity, the metabolic syndrome, and type 2 diabetes mellitus; atherosclerotic cardiovascular disease; neurovascular degenerative disease; osteopenia and osteoporosis; and sleep disorders, such as insomnia or excessive daytime sleepiness.

The pathogenesis of acute-stress-induced disorders can be attributed to increased secretion and effects of the major stress mediators in the context of a vulnerable background.[2,3,9,30-33] Thus, acute allergic attacks may be activated by immune-CRH-induced degranulation of mast cells in the vulnerable organ (for example the lungs or skin). These reactions cause asthma or eczema, respectively. Similarly, migraine headaches could be caused by immune-CRH-induced degranulation of mast cells in meningeal blood vessels, which causes local vasodilatation and increased permeability of the blood-brain barrier; panic or psychotic attacks could be triggered by CRH bursts in the central amygdala that activate a fear response; hypertensive or hypotensive attacks could be caused by stress-induced, excessive sympathetic or parasympathetic system outflow, respectively.

The pathogenesis of chronic-stress-related disorders can also be explained by sustained, excessive secretion and effects of the major mediators of stress and sickness syndromes, which influence the activities of multiple homeostatic systems.[2,3,9,30-36] These disorders thus represent chronic, maladaptive effects of two physiological processes whose mediators are meant to be secreted in a quantity-limited and time-limited fashion but have gone awry. The negative consequences of these effects are both behavioral and somatic.

Behavioral and Somatic Consequences

The behavioral consequences of chronic stress result from continuous or intermittent activation of the stress and sickness syndromes, and prolonged secretion of their mediators.[2,7,8,12,41-47] Thus, CRH, norepinephrine, cortisol and other hormones activate the fear system, which produces anxiety, anorexia or hyperphagia; the same mediators cause tachyphylaxis of the reward system, which produces depression and cravings for food, other substances or stress. These mediators also suppress the sleep system, which causes insomnia, loss of sleep and daytime somnolence. On the other hand, IL-6 and other mediators, possibly in synergy with those mentioned above, generate fatigue, nausea, headaches and other pains. Executive and cognitive systems also malfunction as a result of prolonged, chronic activation of stress and sickness syndromes and people may perform and plan suboptimally and make and pursue the wrong decisions. A vicious cycle is initiated and sustained, in which behavioral maladjustment leads to psychosocial problems in the family, peer group, school and/or work, which sustain or cause further mediator changes and exacerbate behavioral maladjustment. The young, developing brain is particularly vulnerable, as it lacks prior useful experiences to which it can resort.

The somatic consequences of continuous or intermittent activation of the stress and sickness syndromes can be equally devastating (or even worse) than their behavioral consequences.[2,3,7,8,27,31,41-47] In developing children, growth may be suppressed as a result of a hypofunctioning growth hormone axis; in adults, stress-induced hypogonadism can manifest as loss of libido and/or hypofertility, and hyperactivity of the sympathetic system can lead to essential hypertension. Chronic hypersecretion of stress mediators, in individuals with a vulnerable background exposed to a permissive environment, may lead to visceral fat accumulation as a result of chronic hypercortisolism, reactive insulin hypersecretion, low growth-hormone secretion and hypogonadism (Figure 2).[2,3,27,47-52] These same hormonal changes lead to sarcopenia, osteopenia and/or osteoporosis. Visceral obesity and sarcopenia are associated with manifestations of the metabolic-syndrome, such as dyslipidemia (elevated levels of total cholesterol, triglycerides and LDL-cholesterol and decreased level of HDL-cholesterol), hypertension and carbohydrate intolerance or type 2 diabetes mellitus. Genetically or constitutionally vulnerable women of reproductive age may develop polycystic ovary syndrome. Stress-related IL-6 hypersecretion plus adipose-tissue-generated inflammatory hypercytokinemia, as well as hypercortisolism, contribute to increased production of acute-phase reactants and blood hypercoagulation.[49-52] Insulin resistance, hypertension, dislipidemia, hypercytokinemia and blood hypercoagulation lead to endothelial dysfunction and consequently atherosclerosis, with its cardiovascular and neurovascular sequelae.

Chronic-stress-induced immune dysfunction, primarily the TH1 to TH2 switch, increases the vulnerability of individuals to certain infections and autoimmune disorders (Figure 1).[6-8,29-31,34] For instance, the immune dysfunction observed in individuals who are chronically stressed might contribute to the persistence of infection with Helicobacter pylori, granted that this pathogen primarily induces and is defended against through activation of a cellular immune response. The same is true for infections with Mycobacterium tuberculosis and the common cold viruses. Similarly, this switch increases vulnerability to TH2-driven autoimmune diseases, such as Graves disease, systemic lupus erythematosus and some allergic conditions. Increased vulnerability to certain neoplasms and their progression might be another effect of chronic stress, but this issue remains controversial.

Increased levels of CRH and/or stress-system abnormalities have been reported in behavioral and neuropsychiatric disorders, such as hypothalamic oligomenorrhea and amenorrhea, reduced fertility, obligate athleticism, anxiety, depression, post-traumatic stress disorder in children, eating disorders and chronic, active alcoholism ( Box 3 ).[2,3,27,53-55] On the other hand, overproduction of CRH in the brain and in peripheral tissues, as well as disruption of the hypothalamic-pituitary-adrenal axis and the functions of the arousal and sympathetic systems, have been reported in obesity, metabolic syndrome and essential hypertension. Furthermore, dysregulation of the stress-system and autonomic nervous system is a distinctive feature of common gastrointestinal disorders, such as irritable bowel syndrome and peptic ulcer disease.[56]

Box 3 Conditions with altered HPA axis activity2

Increased activity of the HPA axis

  • Cushing syndrome
  • Chronic stress
  • Melancholic depression
  • Anorexia nervosa
  • Obsessive-compulsive disorder
  • Panic disorder
  • Excessive exercise (obligate athleticism)
  • Chronic, active alcoholism
  • Alcohol and narcotic withdrawal
  • Diabetes mellitus
  • Central obesity (metabolic syndrome)
  • Post-traumatic stress disorder in children
  • Hyperthyroidism
  • Pregnancy

Decreased activity of HPA axis

  • Adrenal insufficiency
  • Atypical/seasonal depression
  • Chronic fatigue syndrome
  • Fibromyalgia
  • Premenstrual tension syndrome
  • Climacteric depression
  • Nicotine withdrawal
  • Following cessation of glucocorticoid therapy
  • Following Cushing syndrome cure
  • Following chronic stress
  • Postpartum period
  • Adult post-traumatic stress disorder
  • Hypothyroidism
  • Rheumatoid arthritis
  • Asthma, eczema

Abbreviation: HPA, hypothalamic–pituitary–adrenal.

Consistent with the observation that central or peripheral hypersecretion of CRH seems to be involved in a large number of behavioral and somatic disorders, preclinical and clinical evidence suggests therapeutic potential for CRH type 1 receptor antagonists, such as antalarmin, in the treatment of all or some of these diseases and other neuropsychiatric and somatic entities.[57-62]

Abnormal neuroendocrine, autonomic and immune functions are also present in chronic inflammatory and/or autoimmune and allergic diseases, in fibromyalgia and chronic fatigue syndromes; substantial evidence demonstrates that these abnormalities are related to low CRH activity ( Box 3 ).[2,6-8,29-31,34,63] Similarly, low CRH activity has been implicated in atypical, seasonal depression, postpartum ‘baby blues’ and depression, premenstrual dysphoric disorder and climacteric depression.[2,3,27,64-67] In all these disorders, the problem seems to be cacostasis secondary to inadequate stress-system activity and responsiveness, which influence the functions of the homeostatic systems.

Box 3 Conditions with altered HPA axis activity2

Increased activity of the HPA axis

  • Cushing syndrome
  • Chronic stress
  • Melancholic depression
  • Anorexia nervosa
  • Obsessive-compulsive disorder
  • Panic disorder
  • Excessive exercise (obligate athleticism)
  • Chronic, active alcoholism
  • Alcohol and narcotic withdrawal
  • Diabetes mellitus
  • Central obesity (metabolic syndrome)
  • Post-traumatic stress disorder in children
  • Hyperthyroidism
  • Pregnancy

Decreased activity of HPA axis

  • Adrenal insufficiency
  • Atypical/seasonal depression
  • Chronic fatigue syndrome
  • Fibromyalgia
  • Premenstrual tension syndrome
  • Climacteric depression
  • Nicotine withdrawal
  • Following cessation of glucocorticoid therapy
  • Following Cushing syndrome cure
  • Following chronic stress
  • Postpartum period
  • Adult post-traumatic stress disorder
  • Hypothyroidism
  • Rheumatoid arthritis
  • Asthma, eczema

Abbreviation: HPA, hypothalamic–pituitary–adrenal.

Stress in Modern Societies

We might wonder why modern societies are plagued by clusters of the so-called multifactorial polygenic disorders: obesity, the metabolic syndrome and type 2 diabetes mellitus; hypertension; autoimmunity and allergy; anxiety, insomnia, and depression; and pain and fatigue syndromes. All these disorders are associated with dysfunction of the stress system ( Table 1 ). Such dysfunction, in fact, has a lot to do with the development of these common and frequently comorbid pathologies.[68] In its evolutionary path, the human species experienced environmental stressors, which applied selective pressure upon its genome. Such selection favored ancestors who were efficient at conserving energy, combating dehydration, fighting injurious agents, anticipating adversaries, minimizing exposure to danger and preventing tissue strain and damage. In modern societies, lifestyle has changed dramatically from that of our past. The modern environment and extension of our life expectancy seem to permit the expression of these affluence-related ills.

Table 1 Adaptive responses to evolutionary stressors and related diseases in modern human societies68

Response to survival threat Selective advantage Contemporary disease
Combat starvation Energy conservation Obesity
Metabolic syndrome
Combat dehydration Fluid and electrolyte conservation Hypertension
Combat injurious agents Potent immune reaction Autoimmunity
Allergy
Anticipate adversaries Arousal and fear Anxiety
Insomnia
Minimize exposure to danger Social withdrawal Depression
Prevent tissue strain and damage Retain tissue integrity Pain syndromes
Fatigue syndromes

Stress is ubiquitous and universally pervasive; however, its objective quantification has not been easy. In modern life, statistics show powerful effects of stress early in life, concurrent chronic stress, and socioeconomic status on both the morbidity and mortality of chronic disease.[69-74] Similarly, comparisons between non-Hispanic white people in the US and those in the UK show that the sociopolitical system has a potent effect on the burden of chronic disease—an influence well above and beyond that predicted by socioeconomic status, which can only be interpreted as an individual, chronic, stress-driven cacostasis with a deleterious effect on health.[73]

Finally, analyses of data obtained in the National Health and Nutrition Examination Surveys show that, despite increasing obesity rates, mortality has been decreasing in the US. This decrease probably reflects public health improvements and, most likely, chronic use of pharmacological agents, such as ß-blockers, angiotensin-converting-enzyme inhibitors and statins, which interrupt the pathogenic effects of disturbed homeostatic mechanisms.[74]

Conclusions

The stress response, which occurs when homeostasis is threatened or perceived to be threatened, is mediated by the stress system. Central effectors (including hypothalamic hormones, such as AVP, CRH and pro-opiomelanocortin-derived peptides and brainstem-derived norepinephrine) and peripheral effectors (including glucocorticoids, norepinephrine and epinephrine) of this system regulate the brain’s cognitive, reward and fear systems and wake–sleep centers as well as the growth, reproductive and thyroid hormone axes, and influence the gastrointestinal, cardiorespiratory, metabolic, and immune systems. Malfunction of the stress system might impair growth, development, behavior and metabolism, which potentially lead to various acute and chronic disorders. Our lifestyles and environment in modern societies seem to be particularly permissive for such stress-related disorders.
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Key Points

  • Stress occurs when homeostasis is threatened or perceived to be so
  • The stress response is mediated by the stress system, which is located in both the central nervous system and peripheral organs
  • The main central effectors of the stress system are highly interconnected, and include hypothalamic corticotropin-releasing hormone and brainstem-derived norepinephrine
  • Malfunction of the stress system is associated with behavioral and somatic disorders
  • Stress is a major contributor to psychosocial and physical pathological conditions in humans

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Acknowledgments
This review is partially based on the Geoffrey Harris Memorial Lecture given by the author at the 10th European Congress of Endocrinology, 3–7 May 2008, Berlin, Germany

Remembering America’s finest

Posted: October 18, 2010 in Uncategorized

On Saturday, July 24, 2010, the town of Prescott Valley, AZ, hosted a Freedom Rally.  Quang Nguyen was asked to speak on his experience of coming to America and what it means.  He spoke the following in dedication to all Vietnam Veterans. Thought you might enjoy hearing what he had to say.

“35 years ago, if you were to tell me that I am going to stand up here speaking to a couple thousand patriots, in English, I’d laugh at you.   Man, every morning I wake up thanking God for putting me and my family in the greatest country on earth.
“I just want you all to know that the American dream does exist and I am living the American dream.  I was asked to speak to you about my experience as a first generation Vietnamese-American, but I rather speak to you as an American.
“If you hadn’t noticed, I am not white and I feel pretty comfortable with my people. “I am a proud US citizen and here is my proof.  It took me 8 years to get it, waiting in endless lines, but I got it and I am very proud of it. Guess what, I did legally and it ain’t from the state of Hawaii.  “I still remember the images of the Tet offensive in 1968; I was six years old.  Now you might want to question how a 6 year old boy could remember anything.  Trust me; those images can never be erased.  I can’t even imagine what it was like for young American soldiers, 10,000 miles away from home, fighting on my behalf.
“35 years ago, I left South Vietnam for political asylum.  The war had ended.  At the age of 13, I left with the understanding that I may or may not ever get to see my siblings or parents again.  I was one of the first lucky 100,000 Vietnamese allowed to come to the US.   Somehow, my family and I were reunited 5 months later, amazingly, in California.  It was a miracle from God.
“If you haven’t heard lately that this is the greatest country on earth, I am telling you that right now.  It is the freedom and the opportunities presented to me that put me here with all of you tonight.  I also remember the barriers that I had to overcome every step of the way.  My high school counselor told me that I cannot make it to college due to my poor communication skills.  I proved him wrong.  I finished college.  You see, all you have to do is to give this little boy an opportunity and encourage him to take and run with it. 

 Well, I took the opportunity and here I am.
This person standing tonight in front of you could not exist under a socialist/communist environment.  By the way, if you think socialism is the way to go, I am sure many people here will chip in to get you a one way ticket out of here.  And if you didn’t know, the only difference between socialism and communism is an AK-47 aiming at your head.  That was my experience.

“In 1982, I stood with a thousand new immigrants, reciting the Pledge of Allegiance and listening to the National Anthem for the first time as an American.  To this day, I can’t remember anything sweeter and more patriotic than that moment in my life.
“Fast forwarding, somehow I finished high school, finished college, and like any other goofball 21 year old kid, I was having a great time with my life. I had a nice job and a nice apartment in Southern California.  In some way and somehow, I had forgotten how I got here and why I am here.
“One day I was at a gas station, I saw a veteran pumping gas on the other side of the island.  I don’t know what made me do it, but I walked over and asked if he had served in Vietnam.  He smiled and said yes.  I shook and held his hand.  The grown man began to well up.  I walked away as fast as I could and at that very moment, I was emotionally rocked.  This was a profound moment in life.  I knew something had to change in my life.  It was time for me to learn how to be a good citizen.  It was time for me to give back.
“You see, America is not a place on the map, it isn’t a physical location. It is an ideal, a concept.  And if you are an American, you must understand the concept, you must buy into this concept, and most importantly, you have to fight and defend this concept.  This is about Freedom and not free stuff.  And that is why I am standing up here. 

Brothers and sisters, to be a real American, the very least you must do is to learn English and understand it well.  In my humble opinion, you cannot be a faithful patriotic citizen if you can’t speak the language of the country you live in.  Take this document of 46 pages – last I looked on the internet, there wasn’t a Vietnamese translation of the US Constitution. It took me a long time to get to the point of being able to converse and until this day, I still struggle to come up with the right words.  It’s not easy, but if it’s too easy, it’s not worth doing.

 “Before I knew this 46 page document, I learned of the 500,000 Americans who fought for this little boy.  I learned of the 58,000 names scribed on the black wall at the Vietnam Memorial.  You are my heroes.  You are my founders.
“At this time, I would like to ask all the Vietnam veterans to please stand.  I thank you for my life.  I thank you for your sacrifices, and I thank you for giving me the freedom and liberty I have today. 

 I now ask all veterans, firefighters, and police officers, to please stand.  On behalf of all first generation immigrants, I thank you for your services and may God bless you all.”

The journey from combat to hospitals to rehabilitation and release from military service appeared at the time to be the final leg of our journey in uniform. The journey had begun with military training followed by orders to troop units and combat in Vietnam. The journey was unique for each of us who followed the path from civilian life to duty in jungle fatigues.

Our jobs differed from infantry grunts to artillerymen and aviators, as well as cooks and bakers, who each made different contributions to the conflict. Along the way, we bonded with fellow soldiers. We took pride in our new units with long service in defense of freedom, some reaching back to the Revolutionary War.

 
Our abrupt arrival in the stifling heat and humidity of South Vietnam was a shock. Before we could adjust to the heat of our new surroundings, large transport aircraft, helicopters, and trucks transported novice warriors to new homes – tent cities in exotic settings from highlands to river deltas. Vietnam was a huge country divided into forty-four provinces—each unique and exotic.

The country stretched hundreds of miles from the North Vietnamese border to the mangrove swamps and rice paddies at the southern tip of the country known as Ca Mau. We had never experienced anything quite like it; and the beauty of the land amazed us as we gazed out upon the vast countryside.
Encounters with the enemy would come later. We gradually came to know our opponents – North Vietnamese Army units, as well as Viet Cong guerrillas.

The enemy strategy was to take control of the rural population and defeat the men dressed in the uniforms of the soldiers of the Saigon Government. Although we did not see it at the time, we were part of the larger Cold War struggle. Our war was a proxy war between America and the Soviet Union. It pitted Hanoi against South Vietnam. The Soviet Union and the Peoples’ Republic of China supported Hanoi. The Americans and their Asian allies – South Korea, Australia, and Thailand, backed Saigon.

Our fight was a test of the Cold War containment strategy that had halted Soviet expansion in Europe. In Northeast Asia, the containment strategy had been tested and had held in Korea; but in Southeast Asia, the situation remained fluid and its outcome uncertain.

We did not perceive that we were part of a protracted struggle that would continue far longer than we could imagine. Our participation in the struggle between the two Vietnams endured for over a decade. The long struggle saw the building of a large South Vietnamese defense establishment and the decimation of the indigenous guerrilla force we knew as the Viet Cong, who were virtually annihilated in the conflict. Their leadership, known as the National Liberation Front (NLF), did not learn they were puppets until the cannon were silent.

The NLF– the face of the communist enemy in the South and their few surviving Viet Cong soldiers– were excluded from the victory parade in Saigon celebrating Hanoi’s conquest of the South. Instead, the Viet Cong survivors joined North Vietnamese units. The NLF fared no better. The survivors found no jobs in the new administration of the South they thought they would govern, as their propaganda proclaimed.

Instead, the NLF cadre were offered menial jobs by Hanoi’s generals, who ruled South Vietnam. Some of the NLF survivors fled as boat people in leaking fishing boats to watery graves or new beginnings in distant lands.
The Americans departed following the signing of the Paris Peace Treaty in 1972, taking our prisoners of war with us as we departed. We had sent home 58,000 American dead for burials in cemeteries across America. The South Vietnamese lost a quarter of a million troops. The North Vietnamese lost 1.4 million soldiers in the extended combat. The collateral damage of the war was extensive. Civilian casualties were heavy on both sides. In addition, wounded soldiers filled hospitals from Hanoi to Saigon and from Hawaii to Washington, DC. 

The most severely wounded remained hospitalized indefinitely. The majority of the wounded were treated and released to return to homes they had departed years before.
The final cost of the dramatic events of the long war included animosity on the Home Front. The mood of the country had changed. The war had changed everyone – the soldiers, their families, civilians on the Home Front and those, who elected to oppose the war. Riots, demonstrations, and angry mobs had seized universities, encouraged by a liberal press, Hollywood and folk singers, who became icons of the period. Frequently, the returning veterans discovered they were no longer welcome in their hometowns, which inflicted emotional scars upon battle scared veterans.

Years later soldiers, innocent of their internal scars from traumatic stress, turned to alcohol and drugs to medicate depression and anger that become constant companions, haunting the living with memories of the dead and dying.

 
Many veterans had the good fortune to reside near medical facilities of the Veterans Administration (VA). They learned help was available through the VA. VA psychiatrists provided care and counseling. Those suffering from depression and acute stress received medication. Participation in group therapy sessions was available on a voluntary basis.

Most veterans seeking treatment from the VA expected cures. We thought that after counseling and treatment we could return to normal lives in our communities. I recall asking my counselor how long it would take to cure my Post Traumatic Stress Disorder. The answer was honest, clear and unmistakable. She replied, “You will take it to your grave.” Granted my case was one of prolonged exposure to high stress levels, but I had no inkling of the consequences of my combat duties.

The VA could assist me with therapy, counseling and medication for depression and anger, but at the end of the day the treatment only contained the most severe symptoms of the disorder. There was no cure in sight. Normality was a thing of the distant past.
Veterans spent years together in therapy listening to fellow warriors telling of their long journey through jungle and highlands, rice paddies and mangrove swamps.

We shared homecomings that were frequently, incredibly bitter – wives had deserted their men, families rejected brothers and sons, complete strangers mocked veterans along with Hollywood and the media in daily vitriol that exiled us in our own land. The most common and difficult emotional burden of combat was survivor’s guilt, which was widespread. We confessed our survivor’s guilt because God spared us, while taking the lives of our closest companions – warriors we loved.

Together we had shared brutality beyond description and close combat that never ended. With the loss of our closest companions, we stuffed emotions so we could carry on. Those of us in leadership position had to be ready for combat only hours away; and our soldiers had to be prepared. No tears, no looking back, and no show of weakness were possible leading the young troopers, who needed us. We refused to look back.

We buried our grief so deep in the hidden recesses of our subconscious that it was beyond recall. The unconscious burial of dark memories took with it all memories and emotions of shared times, faces, names and entire operations disappeared into a fog of denial that shielded us from pain too intense to endure, sights too ugly to recall without jeopardizing our ability to function in combat without end. Duty demanded we move on and prepare for enemy contact in the night or certainly in the morning that was not far off. Over time, we became hardened and felt no pain, no remorse, and no emotions other than rage that drove warriors in combat. The subconscious colluded in our need for protection from trauma and memories too heavy to bear. The denial and stuffing of the ugly past protect us from burdens too heavy to endure for years – ten, twenty years – until the subconscious was exhausted by the constant weight of its enormous burden and began to leak visions of the distant past.

When the subconscious began to surrender its burden, warriors entered a new phase of the journey, when brief memories would surface for brief seconds that prompted anger, curses and then nothing. It was gone – the flashback — and we had no idea what had convulsed us in anger and left us trembling and covered in sweat. Sometimes flashbacks came during the day triggered by a smell that resembled the stench of the battlefield, or a word, or sounds. Other flashbacks returned in the night as dreams that tormented old warrior and their loved ones.

Patients with brief exposure to moderate to low stress levels had the best chance of making progress in the quest to rejoin society, although they also faced the difficulty of regression and public display of PTSD symptoms.  Everyday situations often triggered suppressed combat memories – the backfiring of a truck, the slamming of a door in a high wind, an angry confrontation with a co-worker – resulting in angry outbursts, rage, and depression. Such workers were recognized as a problem in the workplace, which usually was followed by a pink slip in the envelope with his or her last paycheck.

Group therapy sessions offered veterans an opportunity to make sense of painful agonies visited upon the survivors of an ugly past. The sessions were difficult for many because it threw together men of dramatically different combat experiences, many of whom exhibited anger and at times violent responses to combat memories. The benefits of the sessions included the opportunity for soldiers to compare their experiences, as well as the dreams and flashbacks that haunted those exposed to prolonged combat. An unintended outcome of group therapy was that it allowed veterans to find men with similar backgrounds, who became friends in a world hostile to veterans in the aftermath of the long and unpopular conflict.

Regrettably, tensions existed among veterans in group therapy sessions that I attended. The therapy revealed many different categories of stress casualties. Men with multiple combat tours in units that saw heavy and prolonged combat were hardened veterans—angry men – without much concern for those exposed to very real, but less intense stress, while supporting combat operations in supply, transportation and support units on airfields or large logistical installations.

The combat support soldiers periodically experienced incoming rockets and artillery, as well as the stress associated with convoy duties that exposed them to sniper fire, mines and occasional ambushes in forward areas. Even cooks and bakers went to sleep with the sound of artillery fire – friendly and enemy—in the night. Medical personnel were exposed to trauma and stress unique to their calling, but every bit as bitter as that experienced by soldiers across the battlefield. Doctors and nurses witnessed the drama of wounded men and women arriving hourly by choppers with wounds of every description.

They tried valiantly to save the lives of the most seriously injured, but invariably many of those they struggled to keep alive died.
Those of us with extended combat duty during multiple tours of duty in Vietnam recognized intuitively that PTSD could not be understood as simply one category of casualties. It was not a matter of one size fits all. We were a diverse population with stress related symptoms that ranged from infrequent exposure to low stress levels to prolonged exposure to combat trauma – high stress levels –over many years. The most severe cases of traumatic stress were normally found among the veterans, who had served as infantrymen in several wars.

Moreover, soldiers had unique tolerances to stress that differed dramatically. Simply the act of putting on a uniform and undergoing military training from dawn to dusk was highly stressful for some. Military training posed no problem and produced little stress for volunteers from farms and rural communities, who hunted all their lives and were accustomed to hard physical labor from dawn until dusk.

Veterans with PTSD spent years in therapy and came to know fellow veterans, their journey into hell, their problems with flashback, their dreams, and the great sorrows they carried. Over time the sharing, counseling, and listening to the experiences of members of the therapy group brought us to an understanding of what had happened to us as the subconscious gradually revealed the hidden past. The friendships formed in the therapy groups led to close associations as we met for coffee and attended veteran’s organizations like The Combat Infantryman’s Association, The Military Order of the Purple Heart, Vietnam Veterans of America, Disabled American Veterans, The American Legion and The Veterans of Foreign Wars.

Friends sat together in the therapy sessions. The senior warriors with multiple combat tours sat with friends with similar experiences. Soldiers with less exposure to danger and stress sat apart. The severely, wounded, senior warriors were a dying breed. They had been wounded multiple times. Typical problems included exposure to Agent Orange, crippling stress that manifested itself in heart disease, diabetes, and cancer.

 These medical conditions aggravated the disabilities veterans brought back from war – gunshot wounds, loss of limbs, lost hearing, impaired lungs, lost vision, and deeply personal wounds that we were only able to share after years of friendship and earned trust. Alcoholism haunted those of us who had resorted to drink to medicate stress in the years before we found VA treatment. Each year our numbers dwindled as trusted comrades lost their struggle for life.

It became obvious to all of us that PTSD was not a single malady with one method of treatment. Both Psychiatrists and patients alike recognized marked differences between PTSD patients who required different approaches to treatment. The most severely disturbed patients required hospitalization. Other PTSD victims required different dosages of medications that varied with the severity of the veteran’s symptoms. Patients exposed to violent trauma and combat stress for extensive periods required more medications and counseling than patients with shorter exposure times to lower stress levels.

Many of the older veterans with extensive service discussed the advantages of segregating patients into groups reflecting the severity of their PTSD symptoms. Such an approach would allow the most seriously injured and aggravated, combat, stress-impaired patients to relate to men and women with similar experiences, reducing the tensions between men and women exposed to dramatically different stress levels.
Discussion of the problem suggested the need for recognition of a hierarchy of PTSD cases in a manner similar to the classification of burn victims in multiple categories reflecting the different treatment required based on the severity of the wound. The following concept of PTSD types is suggested as the basis for further study of the disorder based upon the dramatically different PTSD patients found in VA therapy sessions.

 Categorizations of Post Traumatic Stress Disorder 
 
First Degree Post Traumatic Stress Disorder:
·       Stress Exposure: Short to moderate duration.
·       Trauma: Limited exposure to traumatic injuries.
·       Victim: Mechanic, cook, accident victim, nurse         (depending upon duties), battered wives.
·       Characteristics: Nurturing personality or employed in a non-combat role.
·       Symptoms: Anger, depression, anxiety, and reduced job site effectiveness.
Second Degree Post Traumatic Stress Disorder:
·       Stress Exposure: Extended exposure to stress.
·       Trauma: Typically exposed to extreme cases of trauma.
·       Victims: Combat infantry, intensive care nurse, police and firefighters, rape or incest victim, EMT personnel, and battered wives exposed to abuse over long periods.
·       Characteristics: Insensitive, history of frequent or multiple tours of duty in combat units, career firefighters and police officer serving in high-risk environment.
·       Symptoms: Combative, angry, sleep disorders, suppressed memories, anti-social, experiences flashbacks.
Third Degree Post Traumatic Stress Disorder:
·       Stress Exposure: Routine exposure over many years.
·       Trauma: Routine exposure to severe trauma over many years.
·       Victims: Combat leaders, Special Forces personnel, SWAT team members.
·       Characteristics: Highly trained professional, impersonal and passionless, takes initiative, insensitive personality.
·       Symptoms: Often none for many years, resorts to alcohol as self-medication to control stress and anxiety, considers psychological disorders a sign of weakness, and denies symptoms of PTSD.
 
Fourth Degree Post Traumatic Stress Disorder:
·       Stress Exposure: Extensive exposure to intense stress.
·       Trauma: Routine exposure to violent trauma.
·       Victims: The avenger (Killer Angels – General Lee’s infantry in the Army of Northern Virginia), incest victims exposed to molestation over a period of years, prisoners of war exposed to prolonged torture and deprivation.
·       Characteristics: Fights with rage, combat is personal, long history of suffering and personal loss.
·       Symptoms: Anger, combative, use of alcohol to control stress or grief, and frequently denies symptoms of disorder.

Fifth Degree Post Traumatic Stress Disorder:
·       Stress Exposure: Often life-long exposure to stress.
·       Trauma: Extended exposure to multiple forum of trauma.
·       Victims: Victims of multiple form of PTSD.
·       Characteristics: Incest victim that becomes a combat infantryman in more than one war, or rape victim that works as an intensive care nurse.
·       Symptoms: Symptoms may be suppressed for years; later symptoms emerge including uncontrollable anger, history of substance abuse, depression, flashbacks, and sleep disorders

Categorizations of Post Traumatic Stress Disorder 
 
First Degree Post Traumatic Stress Disorder:
·       Stress Exposure: Short to moderate duration.
·       Trauma: Limited exposure to traumatic injuries.
·       Victim: Mechanic, cook, accident victim, nurse (depending upon duties), battered wives.
·       Characteristics: Nurturing personality or employed in a non-combat role.
·       Symptoms: Anger, depression, anxiety, and reduced job site effectiveness.

Second Degree Post Traumatic Stress Disorder:
·       Stress Exposure: Extended exposure to stress.
·       Trauma: Typically exposed to extreme cases of trauma.
·       Victims: Combat infantry, intensive care nurse, police and firefighters, rape or incest victim, EMT personnel, and battered wives exposed to abuse over long periods.
·       Characteristics: Insensitive, history of frequent or multiple tours of duty in combat units, career firefighters and police officer serving in high-risk environment.
·       Symptoms: Combative, angry, sleep disorders, suppressed memories, anti-social, experiences flashbacks.

Third Degree Post Traumatic Stress Disorder:
·       Stress Exposure: Routine exposure over many years.
·       Trauma: Routine exposure to severe trauma over many years.
·       Victims: Combat leaders, Special Forces personnel, SWAT team members.
·       Characteristics: Highly trained professional, impersonal and passionless, takes initiative, insensitive personality.
·       Symptoms: Often none for many years, resorts to alcohol as self-medication to control stress and anxiety, considers psychological disorders a sign of weakness, and denies symptoms of PTSD.
 
Fourth Degree Post Traumatic Stress Disorder:
·       Stress Exposure: Extensive exposure to intense stress.
·       Trauma: Routine exposure to violent trauma.
·       Victims: The avenger (Killer Angels – General Lee’s infantry in the Army of Northern Virginia), incest victims exposed to molestation over a period of years, prisoners of war exposed to prolonged torture and deprivation.
·       Characteristics: Fights with rage, combat is personal, long history of suffering and personal loss.
·       Symptoms: Anger, combative, use of alcohol to control stress or grief, and frequently denies symptoms of disorder.
Fifth Degree Post Traumatic Stress Disorder:
·       Stress Exposure: Often life-long exposure to stress.
·       Trauma: Extended exposure to multiple forum of trauma.
·       Victims: Victims of multiple form of PTSD.
·       Characteristics: Incest victim that becomes a combat infantryman in more than one war, or rape victim that works as an intensive care nurse.
·       Symptoms: Symptoms may be suppressed for years; later symptoms emerge including uncontrollable anger, history of substance abuse, depression, flashbacks, and sleep disorders

Tribute to our Benefactors

After my retirement, my wife and I settled in the South Carolinian low country.  I came to this place to die and to be buried alongside ancestors, who fought in America’s earlier wars. My intentions were to settle my wife before passing on to a better place. I suffered from wounds and injuries due to combat in Vietnam, as well as the complications of an aging wounded warrior. Army doctors had diagnosed me with Post Traumatic Stress Disorder – a condition that complicates life due to the stress of anger, anxiety, and depression that characterize the disorder. My physical condition steadily declined. The signs were unmistakable. My hearing, vision and even walking became chronic problems, as did skin cancer – the result of exposure to Agent Orange. Pain was a constant companion, which over time made exercising difficult. I put on weight. My explosive temper made friendships problematic; and I settled into the life of an angry recluse.

I medicated my PTSD with alcohol. Unfortunately, my temper and depression made life difficult for my wife. She insisted that I seek help from the VA. I went to a VA clinic and was scheduled to see a resident doctor. He found multiple problems that required treatment. He insisted that I begin an exercise program. He made an appointment for me with Doctor Fahy, the staff Psychiatrist. When I met Doctor Fahy, I was walking with crutches to ease the pain of old back injuries I had recently aggravated. He asked where the crutches came from. I responded that the Army issued them to me following a gunshot wound. Doctor Fahy prescribed medication for my stress, anxiety and temper. He asked if I had a problem with alcohol and I replied, “No problem.  I have plenty of beer and wine in the garage and there’s more where that came from.” He was not amused and strictly limited my use of alcohol.

The medication had an immediate impact on my psychological condition, which improved dramatically. The anxiety, depression and anger were reduced overnight. At Doctor Fahy’s suggestion, I began attending weekly meetings of the PTSD therapy group. I found the group discussions disturbing.  Listening to the discussions I felt my temper getting out of control. They brought back ugly memories I never wanted to think about as long as I lived. I complained to Dr. Fahy saying the discussions were useless. He scheduled me for more appointments and encouraged me to continue to meet with the therapy group.  Over time, I came to know the members of the group, especially the veterans with long service in combat units. We became friends and formed an informal support group. We met for coffee between therapy sessions, where we shared war stories; and we discussed memories of combat that haunted us still.

I had come to the home of my ancestors to die, but I did not die. I am alive and a member of a support group that has helped me during difficult times. Tragically, our support group lost senior leaders with much to share, men who had struggled with PTSD and helped others to cope with their demons – the ugly memories that haunt us still. We repeatedly saw close friends and leaders in the group sicken and die, often in a matter of days. Despite the loss of close companions, new veterans have joined the therapy group with difficult problems as those who came before them did.

It may sound trite, but I have no doubt that the VA saved my life. I could not cope with life until the VA treated my problems — physical, psychological, and social – transforming my life in the process. I no longer depend upon alcohol to get through the day. My pain, depression and anger are under semi-control, although I still have periodic meltdowns and continue to be a recluse. I do not associate with those who persecuted veterans upon our return home. I associate with fellow combat veterans with whom I am at peace.

I wish to extend my heartfelt thanks to the doctors, specialists, psychiatrists and administrators of the Department of Veterans Affairs. Without your help, I could not have made it to greet this morning with new promise of unfulfilled expectations. My family thanks you too, as does Clancy my Labrador retriever.

Andy O’Meara, Pawleys Island, SC, 1 August 2010

Some Memories are too Bitter to Share

By

Andy O’Meara

When I joined the Blackhorse Regiment in 1968, we fought day and night. We observed no holidays, which passed unnoticed in the struggle to halt the flow of communist troops, supplies and units moving into South Vietnam. The demands on the unit were many.

I directed the reconnaissance operations of the Regiment.  I flew with the scouts seeking targets for B-52 strikes, conducted bomb damage assessments when asked to verify an unusually successful strike. I flew with the Regimental Commander when directed; and I managed to find a ride to the major fights of the Regiment. Patton demanded detailed intelligence information on the outcome of every fight; and unless he saw me searching the dead, when the smoke cleared he would raise hell at the evening briefing.

The Blackhorse units in contact with the enemy tended to pursue the fleeing enemy, which posed the possibility that valuable intelligence on the enemy dead would be lost. Consequently, I adopted the practice of catching a ride with a scout ship returning to rearm and refuel, when a major contact was made, so that I was on the ground when the smoke cleared.

The Regimental Commander directed me to coordinate periodically with the Province Headquarters we worked with. And Patton directed me to accompany night ambush patrols to provide feedback on the efficacy of ambush patrolling, since I was the only Ranger trained member on his staff. When Patton directed me to check the ambush patrolling in a unit, I normally gave the intelligence officer a call the day before, letting him know I would accompany one of their ambush patrols the following night.

Regrettably, the patrols sent out by the cavalry squadrons tended to be last minute details. A platoon sergeant would receive word late in the day from the First Sergeant telling him that it was his turn to provide an ambush patrol. The troopers were dead tired from a long day of reconnaissance operations. Moreover, they had limited training in combat patrolling. The result was that the Regimental patrols tended to be listening posts at best. I informed the Commander that most of our patrols were ineffective.

The ambush patrols of attached infantry battalions of the 1st Division were far superior. The infantry units had many Ranger trained leaders, who were well equipped to lead ambush patrols. We in the Cavalry didn’t have Ranger trained leaders with the exception of an occasional volunteer.

When calling an infantry unit to inform them I would be joining them on an ambush patrol, I often baited them by saying that I didn’t want to waste my time on a patrol that didn’t make any kills, knowing full well they would rise to the occasion. Their approach was to select a trail that appeared to have been used recently to run messengers and supplies between the base camps in the jungle and NVA units located in the villages in the western third of the Regimental AO.

 The battalion staff supported the planning of the ambush. The intelligence officer and the operations officer selected an ambush site on the trail showing the best signs of recent enemy use. They coordinated with other units warning them to stay clear of the area; and they alerted the supporting artillery units of the patrol’s location and warned them not to adjust illumination flares during the time the patrol would be moving into their ambush site.

The patrolling techniques taught at the Ranger School were used by the infantry patrols. The infantry company selected to conduct the night patrol spent the entire day preparing for the patrol.  After the patrol members received the order, made a through map reconnaissance of the area, and rehearsed the actions during the patrol; they were allowed to rest. The company commander would personally inspect the patrol prior to their departure.

At dusk the patrol would move out and take up a concealed position well removed from the Battalion base. They would hold up in their position until well after sun set, allowing eyes and ears to adjust to the night light and night sounds. When they had time to adjust their night vision, they would take up their patrol formation and move to the ambush site. The troops would form an L shaped ambush in accordance with the pre-rehearsed patrol order. Claymore mines would be placed to get the best coverage of the enemy soldiers on the trail. All actions would be taken in complete silence.

Needless to say I always had a positive report to make on the infantry ambush patrols that usually made enemy contact that produced valuable intelligence. Colonel Patton always made a point of complimenting units that made enemy contact, which meant I was always welcome in the unit.

********

When the day was done and the night shift had taken their post in the tactical operations center of the intelligence section, it my custom to ask the radio operator to clean my weapons and to top off my magazines with pure tracer ammunition – making it easier to sense each round fired. This was seldom a hardship because the night shift was usually quiet; and if a fight developed, I would claim my side arms and await instructions from the Commander.

One evening I returned especially wet and worn from the activities of the day. My weapons had been fired and my magazine needed to be refilled. After getting the briefing from the Tactical Operations Center (TOC), I turned to the radio operator and asked him to clean my weapons, if the shift were quiet. The radio operator asked me: “Major, why are you so aggressive.” He was a newly assigned trooper. He had a smirk on his face – no doubt the result of getting most of his combat indoctrination from Walter Cronkite and the liberal media.

I didn’t know what to say. I assumed that everyone felt about the war as I did: filled with anger at the atrocities the enemy frequently inflicted upon innocent civilians – actions that revealed the brutal nature of the NVA and were often ignored by the liberal, American media. The constant barrage of negative reporting on the war was changing opinions on the home front, which in due course influenced the outlook of our draftee soldiers.

I returned to my tent that I shared with the members of the intelligence staff with a heavy heart. It was clear that a serious problem lay behind the innocent remark of the radio operator. The Army fighting the war was becoming isolated from opinion at home – opinion that had begun to question the purpose of the War. More serious was the implication of the soldier’s question suggesting that he had more faith in the liberal media than in his leaders.

I sat down on my bunk. I pulled my stationary box from under my bunk. I opened it and took out pictures taken during my first tour of duty. Pictures of close Vietnamese friends were now pictures of the dead. Reminders of glad memories once prompted by the photos had turned to grief and anger for lost comrades. I could not look at the pictures without grief and feelings of hatred for our enemy; but I couldn’t get rid of the pictures, because I had been very close to my Vietnamese friends.

***********

I first arrived in Vietnam in 1962. I was the first advisor assigned to the mechanized infantry company I would help train and advise. The Vietnamese called the company a troop because it was part of the 1st Cavalry Regiment.

The soldiers took an instant liking to me and looked out for me. My ability to speak Vietnamese was poor and they helped me. They asked if I would like them to find me a girl friend to keep me company and help me to improve my Vietnamese fluency. I responded that I was newly married and a Roman Catholic. Instead of a girl friend, I asked them to tell me when we were in a Catholic resettlement village composed of people, who fled communism when the French departed the North in 1954. I told them I would like to attend Mass, if we were in Catholic village long enough for me to attend services.

Normally we passed through the villages without stopping during our operations against the Viet Cong in 1962 – 1963.  One two occasions, we took up positions around villages with Roman Catholic Churches. In the first instance the village was threatened by the communists and in the second case we occupied an assembly area near a Catholic resettlement village, while awaiting the start of larger operations.

In the first case our missions was to reinforce an infantry battalion of the Eighth ARVN Regiment guarding a Leper Colony that was overrun twice during my time in Country, inflicting heavy casualties on the Vietnamese Soldiers and stealing the medical supplies from the medical clinic. The Colony was run by French Nuns. They had a Catholic Church and a French Priest, who conducted daily mass early each morning. I would arise and wash in the dark to attend the services with my Classmate, Lieutenant Bill Mullen. We also shared our daily meal together with the ARVN Regimental Staff.

It was boring duty, because the enemy refused to attack, when we were prepared for them. Fortunately, I had Bill’s company, which was an unexpected joy in a boring assignment. One night we had an unexpected bit of excitement, when a large explosion occurred in the vicinity of the bridge on the road to the Leper Colony.

In the morning we investigated to determine the source of the disturbance and found a large hole in the road near the bridge. We counted nineteen feet in the vicinity of the crater. Evidently the VC were carrying a large shape charge – with the primer already set – on a litter made of wooden planks. We surmised that one of the VC lost his footing or grip on the litter jarring the primer and detonating both the primer and the shape charge. The foot count – ten left feet – indicated that at least ten men were assigned as security or litter carriers. The torsos of the dead had been demolished by the devastating blast of the cratering charge intended to take down the bridge. The directional blast of the shape charge blew a deep hole in the road as well as blowing away everything above the litter, sparing the sandals and feet of the aspiring sappers.

When the guard mission of the leper Colony came to an end the, Mechanized Infantry Troop        (Company) I advised received orders to proceed to the North. We participated in several small operations and then were directed to proceed to Dong Xoai to await further orders. Dong Xoai was a resettlement village carved out of the jungle. The majority of the population was Roman Catholic. The village was protected by a company of Regional Force militia and an Armored Car Troop, a sister unit of the 1st Cavalry Regiment. The villagers had constructed a humble church built of hand sawed lumber with corrugated sheet steel roofing.

After we established our assembly area in Dong Xoai, a soldier alerted me that mass was about to start in the village church. I stank. We had been in the field for weeks; and I had not had a chance to shower. I felt unworthy to enter the church, but decided to sit in the last row to avoid offending the congregation. I removed my helmet and slipped into the last row. An altar boy spoke to the Priest, who stopped the mass and came back and insisted that I take a seat in the front row. He would not continue until I came forward and sat in the first row of seats. I was embarrassed, but pleased to be able to participate in a Latin Mass, which I understood.

After the mass, the congregation surrounded me and made me feel welcome. They had never had an American Advisor stay in their village. They all knew of JFK’s pledge in his inaugural speech to bear any burden to preserve liberty. They believed that I was a living symbol of that pledge to help them in their struggle to build a country free of communism.

I was invited into the homes of the parishioners, many of whom were members of the Cavalry Troop stationed in the village. I was fed the best that poor people had to offer and they made me feel as if I were a son or brother of their own. It was the most touching experienced I have ever known. The demonstration of love and appreciation was sincere, even if I was a very modest symbol of President Kennedy’s pledge to protect people threatened by communism.

They asked me to pose for pictures with them, which I did. Those pictures became prize possessions that I treasured long after I left the village.

The communists hated the Vietnamese people, who chose to flee the Red River Valley, when the French pulled out in 1954. They were totally unsuccessful in infiltrating the Roman Catholic community, who had seen the crimes of the communists in the North. Consequently, they resolved to overrun and kill every man, woman and child in the Roman Catholic villages that fled the north. Two years after I departed South Vietnam in the fall of 1963 I received word that Dong Xoai had been overrun by soldiers from North Vietnam. They killed everyone and they torched the village. Nothing remains of Dong Xoai except the ruins of a camp built on the location of the village by American Special Forces later in the war.

The pictures I treasured as reminders of the love and generosity of the people of Dong Xoai suddenly became painful reminders of the massacre of the innocent villagers, who attempted to flee communism. I was stunned by the news. I kept the pictures, because they still held precious memories, even if my fallen friends were now reunited in the Kingdom of God.

I didn’t know how to tell my new radio operator how much I loved those people the communists had slain without mercy. However, I realized that perhaps the picture could speak for me. I took one of pictures of me with several of the parishioners of the Catholic Church in Dong Xoai to the operations draftsman. I showed him the picture and asked him if he could frame it on chart board and cover it with acetate to protect it. And I asked him to print on the chart board below the picture the words: “Charlie has killed all of these people except one.” The draftsman said he would have it for me in the morning.

That was the best I could do by way of explanation. I could not speak of the events, which were too emotionally charged for me to mention.  Early the next morning the draftsman gave me the picture he had mounted with the inscription that told of the fate of the Vietnamese people, who were my friends. I took the picture to my M577 command track and I mounted the picture with tape above the radios. It told a story I could not tell. I hoped it would help the new member of the intelligence section to understand that Major O’Meara was not aggressive. I had not invaded North Vietnam. Nor had I slain innocent villagers from the homeland of the North Vietnamese soldiers, who were ravaging the villages of South Vietnam in savage attacks that went unreported in our news media.

I received no more questions from my radio operator, who gained some insight into the burden of sorrow I carried with me into battle, as well as the anger I harbored for those who butchered the innocent men, women and children of Dong Xoai.