A veteran of the wars in Iraq and Afghanistan, former Marine Capt. Timothy Kudo thinks of himself as a killer — and he carries the guilt every day.

"I can't forgive myself," he says. "And the people who can forgive me are dead."

With American troops at war for more than a decade, there's been an unprecedented number of studies into war zone psychology and an evolving understanding of post-traumatic stress disorder. Clinicians suspect some troops are suffering from what they call "moral injuries" — wounds from having done something, or failed to stop something, that violates their moral code.

Though there may be some overlap in symptoms, moral injuries aren't what most people think of as PTSD, the nightmares and flashbacks of terrifying, life-threatening combat events. A moral injury tortures the conscience; symptoms include deep shame, guilt and rage. It's not a medical problem, and it's unclear how to treat it, says retired Col. Elspeth Ritchie, former psychiatry consultant to the Army surgeon general.

"The concept ... is more an existentialist one," she says.

The Marines, who prefer to call moral injuries "inner conflict," started a few years ago teaching unit leaders to identify the problem. And the Defense Department has approved funding for a study among Marines at California's Camp Pendleton to test a therapy that doctors hope will ease guilt.

But a solution could be a long time off.

"PTSD is a complex issue," says Navy Cmdr. Leslie Hull-Ryde, a Pentagon spokeswoman.

Killing in war is the issue for some troops who believe they have a moral injury, but Ritchie says it also can come from a range of experiences, such as guarding prisoners or watching Iraqis kill Iraqis as they did during the sectarian violence in 2006-07.

"You may not have actually done something wrong by the law of war, but by your own humanity you feel that it's wrong," says Ritchie, now chief clinical officer at the District of Columbia's Department of Mental Health.

Kudo's remorse stems in part from the 2010 accidental killing of two Afghan teenagers on a motorcycle. His unit was fighting insurgents when the pair approached from a distance and appeared to be shooting as well.

Kudo says what Marines mistook for guns were actually "sticks and bundles, like you'd seen in old cartoons with hobos." What Marines thought were muzzle flashes were likely glints of light bouncing off the motorcycle's chrome.

"There's no day — whether it's in the shower or whether it's walking down the street ... that I don't think about things that happened over there," says Kudo, now a graduate student at New York University.

"Human beings aren't just turn-on, turn-off switches," Veterans of Foreign Wars spokesman Joe Davis says, noting that moral injury is just a different name for a familiar military problem. "You're raised 'Thou shalt not kill,' but you do it for self-preservation or for your buddies."

Kudo never personally shot anyone. But he feels responsible for the deaths of the teens on the motorcycle. Like other officers who've spoken about moral injuries, he also feels responsible for deaths that resulted from orders he gave in other missions.

The hardest part, Kudo says, is that "nobody talks about it."

As executive officer of a Marine company, Kudo also felt inadequate when he had to comfort a subordinate grieving over the death of another Marine.

Dr. Brett Litz, a clinical psychologist with the Department of Veterans Affairs in Boston, sees moral injury, the loss of comrades and the terror associated with PTSD as a "three-legged stool" of troop suffering. Though there's little data on moral injury, he says a study asked soldiers seeking counseling for PTSD in Texas what their main problem was; it broke down to "roughly a third, a third and a third" among those with fear, those with loss issues and those with moral injury.

The raw number of people who have moral injuries also isn't known. It's not an official diagnosis for purposes of getting veteran benefits, though it's believed by some doctors that many vets with moral injuries are getting care on a diagnosis of PTSD — care that wouldn't specifically fit their problem.

Like PTSD, which could affect an estimated 20 percent of troops who served in Iraq and Afghanistan, moral injury is not experienced by all troops.

"It's in the eye of the beholder," says retired Navy Capt. William Nash, a psychiatrist who headed Marine Corps combat stress programs and has partnered with Litz on research. The vast majority of ground combat fighters may be able to pull the trigger without feeling they did something wrong, he says.

As the military has focused on fear-based PTSD, it hasn't paid enough attention to loss and moral injury, Litz and others believe. And that has hampered the development of strategies to help troops with those other problems and train them to avoid the problems in the first place, he says.

Lumping people into the PTSD category "renders soldiers automatically into mental patients instead of wounded souls," writes Iraq vet Tyler Boudreau, a former Marine captain and assistant operations officer to an infantry battalion.

Boudreau resigned his commission after having questions of conscience. He wrote in the Massachusetts Review, a literary magazine, that being diagnosed with PTSD doesn't account for nontraumatic events that are morally troubling: "It's far too easy for people at home, particularly those not directly affected by war ... to shed a disingenuous tear for the veterans, donate a few bucks and whisk them off to the closest shrink ... out of sight and out of mind" and leaving "no incentive in the community or in the household to engage them."

So what should be done?

"I don't think we know," Ritchie says.

Troops who express ethical or spiritual problems have long been told to see the chaplain. Chaplains see troops struggling with moral injury "at the micro level, down in the trenches," says Lt. Col. Jeffrey L. Voyles, licensed counselor and supervisor at the Army chaplain training program in Fort Benning, Ga. A soldier wrestling with the right or wrong of a particular war zone event might ask: "Do I need to confess this?" Or, Voyles says, a soldier will say he's "gone past the point of being redeemed, (the point where) God could forgive him" — and he uses language like this:

"I'm a monster."

"I let somebody down."

"I didn't do as much as I could do."

Some chaplains and civilian church organizations have been organizing community events where troops tell their stories, hoping that will help them re-integrate into society.

Some soldiers report being helped by Army programs like yoga or art therapy. The Army also has a program to promote resilience and another called Comprehensive Soldier Fitness to promote mental as well as physical wellness; some clinicians say the latter program may help reduce risk of moral injury but doesn't help troops recognize when they or a buddy have the problem.

Nash says the Marines are using "psychological first aid techniques" to help service members deal with moral injury, loss and other traumatic events. But it's a young program, not uniformly implemented and just now undergoing outside evaluation for its effectiveness, he says.

At Camp Pendleton, the therapy trial will be tailored to each Marine's war experiences; troops with fear-based problems might use a standard PTSD approach; those with moral injury may have an imaginary conversation with the lost person.

Forgiveness, more than anything, is key to helping troops who feel they have transgressed, Nash says.

But the issue is so much more complicated that wholesale solutions across the military, if there are any, will likely be some time coming.

Many in the armed forces view PTSD as weakness. Similarly, they feel the term "moral injury" is insulting, implying an ethical failing in a force whose motto stresses honor, duty and country.

At the same time, lawyers don't like the idea of someone asking troops to incriminate themselves in war crimes — real or imagined.

That leaves a question for troops, doctors, chaplains, lawyers and the military brass: How do you help someone if they don't feel they can say what's bothering them?

Related stories:

• Freshly home, troops face tough few months
• Hip-hop lyrics reveal veterans' sharp edges
• Wearing black on "alive day"

Rachael Rettner
MyHealthNewsDaily

Women who undergo fertility treatments may find the situation so distressing that they develop post-traumatic stress disorder (PTSD), a new study says.

In the study, close to 50 percent of participants met the official criteria for PTSD, meaning they could be diagnosed with the condition.

That's about six times higher than the percentage of people in the general population who suffer from PTSD (8 percent.)

The findings suggest the definition of PTSD may need to be changed so that its causes include potentially traumatic experiences such as infertility, said study researcher Allyson Bradow, director of psychological services at Home of the Innocents, a nonprofit organization that helps families in need in Louisville, Ky.

Currently, the definition of PTSD says people must have experienced or witnessed a life-threatening event, or event that could cause serious injury.

"The definition of trauma should be expanded to include expectations of life," said Bradow, who went through fertility treatments herself, and conducted the study as a doctoral student at Spalding University in Louisville. "Having children, expanding your family, carrying on your genetic code — that's an instinctual drive that we have as human beings. And when that is being threatened, it's not necessarily your life being threatened, but your expectation of what your life can be or should be like," she said.

The finding also shows that a greater effort should be made to counsel those who go through fertility treatments, to help them cope with the emotional and psychological effects of the experience, Bradow said.

Coping with infertility
Bradow had her first child without any trouble at age 26. But when she and her husband tried to conceive a second child several years later, they were not able to. The couple was diagnosed with secondary infertility, which refers to infertility experienced after a couple has a child.

"The general diagnosis of infertility, or not being able to have a baby, is kind of this giant earthquake that rocks your world. And then, there's all the aftershocks," of fertility testing and treatment, Bradow said.

Bradow said the symptoms she experienced during fertility treatment went beyond those of depression and grief, conditions previously linked to fertility treatment. Others she spoke with felt the same.

To find out how widespread these feelings were, Bradow and colleagues surveyed 142 people who had undergone fertility treatments, and who visited online support groups for infertility. Survey participants — 97 percent of whom were women — completed an online survey to assess their symptoms of PTSD. They were asked to consider their infertility diagnosis and fertility treatment as their traumatic event.

About a third of participants had been trying to conceive for one to two years, and about 60 percent had undergone fertility treatments for more than a year.

Overall, 46 percent met the criteria for PTSD. Among this group, 75 to 80 percent said they felt upset at reminders of their infertility, such as seeing commercials for baby diapers. Other common symptoms included feeling distant or cut off from people, or feeling irritable. Many also said they felt hopeless, and had changes in their personality.

Need for counseling
During her treatment, Bradow said no one mentioned anything about how it would affect her emotionally or psychologically.

"They're focused on getting you pregnant…and that's their job," Bradow said. "But we also have to consider the psychological impact of what happens when you're getting medical interventions for this," Bradow said. She eventually became pregnant again, through artificial insemination, and had her second daughter at age 31.

Ideally, Bradow said, mental health counseling should be a required part of fertility treatment. However, this may be a long way off, partly because fertility treatment is not usually covered by health insurance, and doctors may be reluctant to give their clients an extra cost, Bradow said.

Bradow presented her findings last week at the American Psychological Association meeting in Orlando, Fla.

Related:

• 11 Big Fat Pregnancy Myths
• Hypersex to Hoarding: 7 New Psychological Disorders
• 5 Myths of Fertility Treatments 

Shawn Thew / EPA

US Secretary of State Hillary Clinton appeared on a large video screen at the 19th International AIDS Conference this week. Many presentations target women, who make up more than a quarter of new HIV infections in the U.S.

Del’Rosa Winston thought she’d done everything right. She kept herself in steady employment, and waited until she was married to start having children. When her marriage ended, she started having regular HIV tests, just in case. So when she settled into a new, steady relationship, she never dreamed she’d end up infected with the AIDS virus.

“I had a job. I had been in the military. I was educated,"  said Winston, a soft-spoken, well-groomed woman with fashionably cropped red hair. "I just got it from a straight man in a monogamous relationship."

More than a quarter of new infections in the United States every year are in women, and of the 1.1 million Americans with the AIDS virus, 280,000 are women, according to the Centers for Disease Control and Prevention. Black women are especially vulnerable – their infection rate is 15 times the infection rate for white American women.

Winston’s smooth skin and easy smile represent the hidden face of the AIDS epidemic in the United States – the people who don’t look like “typical” HIV patients. The 50-year-old mother of three hopes that speaking out at the 19^th International AIDS Conference, being held in Washington, D.C., will help reduce the stigma and ignorance that fuel the spread of the virus.

 “There are so many people who are getting it because they loved someone,” Winton told NBC News in an interview. Winston couldn’t wait to be in a steady, safe relationship so she could stop using condoms, which she found uncomfortable to use. Her boyfriend, who has since died, told her he had no idea he was infected. But he was, and so was Winston. “We didn’t fit the parameters of what an HIV-positive person looked like,” she said.

She can remember the moment in 1990 when she was told her test came back positive. “The room was gray,” she said. “Like stainless steel. I know there were objects in it but I couldn’t see them. I just flowed like water to the floor.”

Health experts at the conference say they are trying to find new and better ways to reach not only the people at the highest risk – young gay and bisexual men – but others, like Winston, who may not intuitively know how easily and insidiously the virus can move during a moment of passion.  “Everyone’s at risk, whether you have the greatest trust relationship or not,” Winston, who now works as an HIV counselor in Atlanta, said.

Health experts are also trying to figure out some of the factors that make women vulnerable and keep them from protecting themselves even if they do understand the risks. Winston has some ideas – women are often too busy looking after others. “We put everyone else first – kids, school, even the PTA. We get into the mind frame that we don’t have to care for ourselves,” she said.

Another factor may be domestic abuse. A team at the University of California San Francisco published a study on Monday showing that physical and sexual abuse and trauma are major factors affecting which women become infected.

“For a long time we have been looking for clues as to why so many women are becoming infected with HIV and why so many are doing poorly despite the availability of effective treatment,” said Dr. Edward Machtinger, who led the study. “Women who report experiencing trauma often do not have the power or self-confidence to protect themselves from acquiring HIV.”

Their team did a study called a meta-analysis, looking at data from other studies involving 5,900 women. They found 30 percent of women infected with HIV had post-traumatic stress disorder, or PTSD, compared to 5 percent of the general population.  Twice as many women with HIV reported they had been victims of partner violence as women without the virus, they found.

Kat Griffith thinks she knows why. The slender redhead from Peoria, Illinois has been HIV positive for 21 years and she blames a violent boyfriend from high school. “I had a jealous and controlling partner who called me names, demeaned me,” she said. “I had no self-esteem.”

But Griffith went away to college and, she thought, started a fresh new life. “I knew that HIV could affect me and I thought I asked all the right questions,” she said. “But my abuse made me feel I was not worthy of protection." Her college boyfriend infected her.

Women may often put others first but they also lack a good way to protect themselves, Griffith noted.

For years, researchers have been looking for ways to protect women against the virus. There’s been hit-and-miss progress with microbicides – gels or creams that women can use quietly to reduce the chance they’ll become infected during sex. On Tuesday, researchers will announce the start of an advanced, Phase 3 trial of a device called a vaginal ring impregnated with dapivirine, a drug used to treat people with HIV. Researchers will enroll 3,500 women in the two-year study to be conducted in Africa, where half of all HIV patients are women.

Studies have shown that microbicide gels or creams can work - at the last AIDS conference in Vienna in 2010, researchers reported on one that reduced a woman’s risk of infection by 39 percent. But other studies haven’t done so well and experts fear inconsistent use may be one problem.

A flexible, silicone ring may be easier to use and less intrusive than a gel that must be applied before and after sex, the researchers hope. So does Griffith. “After 30 years, we still do not have a completely female controlled prevention technique,” she said.

Getty Images stock

Dreams can serve as your brain's personal psychotherapist by helping process bad memories, experts say.

Ever since the dawn of humanity, people have wondered about the purpose of dreams. We’ve imbued these mental meanderings with all sorts of powers, from forecasting the future to providing a window into the soul.

But scientists say they now know what dreams are for: they sooth the sting out of troubling memories. And when dreams don’t do their job, horrific memories can take over a person’s life, as they do with PTSD, a new study suggests.

Matthew Walker and colleagues at the University of California, Berkeley, found that the brain uses dreams to strip the emotional content from memories of painful events.

Here’s how the researchers think it works. During dream, or REM, sleep, our brain chemistry changes, leaving us with lower levels of stress hormones. While we’re in this quieter state, the brain mulls over what happened and then files away the memory – but with less emotion attached.

 So, when everything works right, when we later recall these events we’ll remember what happened, but less of the pain associated with them.

Walker and his colleagues tested their theory in an intriguing, but simple, experiment.

The researchers asked 35 healthy volunteers to lie in a brain scanner while looking through a series of 150 images, which ranged from bland to emotionally jarring. One image might show a tea kettle, for example, while another might show the aftermath of a horrific car accident. As they were looking at the images, the volunteers were asked to rate the emotional intensity of what they were viewing.

Half the volunteers looked at the images in the morning, while the other half looked at the images just before bedtime. Twelve hours later the volunteers were asked once again to look at and to rate the images while being scanned. This meant that half the volunteers had a night’s sleep in between scans.

What the second set of scans and ratings showed was telling. Volunteers who had slept through the night rated the horrific photos as far less emotionally charged – and their brain scans showed a much lower level of activity in the amygdala, a brain region central to emotional processing.

It’s like dreams become the brain’s psychotherapist, Walker explains. Just as we can benefit from reviewing disturbing events in the safety of a therapist’s office, our brain benefits from processing these same types of events in the quieter dream state.

Walker suspects that the system short-circuits in PTSD sufferers because their brains are  constantly charged up even during dreams. And research in veterans with PTSD appears to bear this out, Walker says. When veterans with PTSD are given medications that knock back a neurotransmitter that keeps the brain in an excited state, sleep appears to improve symptoms of the disorder.

 “We’re hoping to provide the mechanism by which that drug has its effect,” Walker says.  

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