CHAPTER 1
Operator Syndrome
"Every time I see a new primary doctor, VA or civilian, they are completely overwhelmed by the sheer number and severity of the different medical issues I have. Nobody knows how to treat me. I'm completely different from any other patient they've had.
"For over ten years I struggled to understand why I am the way I am, and to know what was really wrong with me. Then I came across an article on Operator Syndrome and was like, 'Holy shit, I'm normal!' I went from feeling totally alone to being part of the tribe again.
"It's hard to quantify the change I have experienced in the last year to simply understanding that I wasn't just 'fucked up.' Knowing I wasn't alone in that I was dealing with some very heavy things, and knowing that there was a community forming to tackle them together, gave me hope. I've been able to access care that isn't widely known, or even 'authorized' yet for certain conditions."
-Clay Jensen, U.S. Army Master Sergeant (Ret.),
Special Operations Team-Alpha (SOT-A), 7th Special
Forces Group, Other Government Agency (CIA)
contractor, with seven deployments to
combat zones from 2001 to 2008
"No one warned us about this. As a SEAL wife, I knew that I could lose him or that he could come back wounded or without limbs. These were the hard realities I actually prepared for. But no one ever told us that they would come back from war, looking perfectly fine, and be so completely changed. That our future would be so drastically altered by silent injuries. It makes recovery that much harder because no one thinks anything is wrong, the Operators included."
-Tania Beaudoin, licensed clinical social worker,
U.S. Navy SEAL spouse
"When I teach current and prior operators about Operator Syndrome, I see lightbulb moments in the room, which is usually followed by an intense sense of relief. So many of them have been told over and over again that there is nothing wrong with them-that their MRI was normal, or their T-levels were normal (according to the branch's standard), and that it must be PTSD or some other mental health 'issue.'"
-Dr. Jennifer Byrne, U.S. Air Force veteran,
Special Operations spouse
"When educating operators on Operator Syndrome, the most common response is: 'How did you know?' This response is usually expressed with a tone of relief and a subtle smile. For the operator, it marks a moment of validation and a glimmer of hope: 'Maybe I'm not alone.' Understanding that their brain is injured and they aren't broken illuminates a light at the end of the tunnel."
-Hoagie, Special Operator (Ret.)
I magine a male medical patient in his late thirties who describes the following symptoms to his doctor: low mood, insomnia, irritability, low motivation, low energy, and poor concentration. The patient's expression is flat, and his face looks weary. His shoulders are slumped a little, and he stares at the floor a lot. During the clinical interview, he acknowledges that he has been drinking heavily for the past few months and arguing more with his girlfriend. He doesn't understand what is wrong with him. He's never been like this before.
In most modern medical settings, this patient is virtually guaranteed to receive a diagnosis of major depressive disorder and probably at least one or two other psychiatric disorders. If he's a service member or veteran, he's also likely to be diagnosed with PTSD. Prescriptions will quickly follow. Over a short period of time, the patient is likely to find himself with a daily regimen of at least two antidepressant medications (Prozac? Wellbutrin? Effexor?), sleeping pills (Ambien? Prazosin?), and possibly a mood stabilizer (Lamotrigine?), a benzodiazepine (Xanax?), or both. Many veterans report being prescribed over twenty different medications at a time by VA clinicians.
The doctor will also probably refer the patient for psychotherapy, typically with a social worker or masters-level mental health counselor. The patient will then likely sit on a waiting list for up to three or four months-or even more. When finally seen, his therapist will be well-intentioned, supportive, thoughtful, even kind. They will encourage the patient to adopt a psychological perspective toward his suffering. It's all in your head, they might suggest. The therapist will likely coax the patient to talk at length about his childhood and adult experiences. The focus will be on adverse, stressful, or traumatic experiences, past and current. The therapist will also put an emphasis on relationships and negative emotions, questioning at every session about suicidal thoughts and the presence of firearms in the patient's home.
But what if the root cause of this patient's torturous symptoms is a severe pathophysiological dysfunction-at the molecular and cellular level-which can be identified with a simple blood test? For example, what if he has an endocrine disorder-specifically hypogonadism? Very low testosterone could cause all of the symptoms he described, but virtually no practitioner in the mental health field routinely checks for hormonal dysregulation. This almost never happens! Neither Veterans Affairs (VA) nor the Department of Defense (DOD) include hormone blood lab panels as part of their standard operating procedures.
Obviously, being treated for depression while you have a missed diagnosis of hypogonadism almost certainly means you are being treated for the wrong illness. Important insights might still emerge from therapeutic conversations. Psychiatric medications may help a little, although it is also quite likely that prescribing psychiatric medications for a pathophysiological dysfunction will cause more problems than it solves.
What would we think of a baseball batting coach attempting to help hitters by focusing primarily on their childhood, adverse life experiences, emotions, and relationship history- all while ignoring the physical aspects of human performance? We would think that coach is unlikely to be of much use to individual players or to the rest of the team.
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Over the past thirty years, I've been a faculty member at several large, multidisciplinary academic medical school psychiatry departments, and not one of them had an endocrinologist. The faculty included psychiatrists, psychologists, nurses, social workers, statisticians, sociologists, and even geneticists-but no endocrinologists.
More broadly, the entire mental health field seems to have carved itself apart from the rest of biology and medicine. Rather than hear a patient's "psychological" symptoms as certain evidence of "psychopathology," perhaps it is time to understand that many psychological or social difficulties are second- and third-order effects of pathology elsewhere in the body?
I and many others believe that we must take a whole systems approach. This obviously includes the nervous system, but it should also not overlook the endocrine, musculoskeletal, perceptual, pulmonary, digestive, and cardiac systems, as well as others. Beyond the body, there are family, community, and occupational systems, and for the SOF community specifically, there are systems to consider within military units, transition services, Veteran Affairs, and other organizations- again, a truly whole systems approach
In our 2020 medical journal article, several of us proposed a framework to better understand and address the complex and unique injuries sustained during a typical career in military special operations:
Operator Syndrome may be understood as the natural consequences of an extraordinarily high allostatic load; the accumulation of physiological, neural, and neuroendocrine responses resulting from the prolonged chronic stress; and physical demands of a career with the military special forces.2
None of this is to say that mental health concerns are not relevant to operators; they most certainly are, and in a variety of ways. But the heavy emphasis we have placed on psychiatric disorders, particularly in the context of a SOF suicide epidemic, is misguided. We've placed PTSD-and, to a lesser extent, other psychiatric disorders-in the foreground, while allowing other chronic medical problems to drift into the background, where they often go ignored and forgotten.
I believe it is time we switch this foregrounded emphasis on psychiatric illness with the overlooked background of physiological injuries, chronic medical problems, and social challenges. Against traditional diagnoses and treatments, my opinion may seem counterintuitive, but I believe that an exclusive focus on psychiatric disorders fails to address many of the root causes of mounting SOF suicides.
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The military special operations community is unlike any other. They have unique selection and training, undergo unique mission sets, sustain unique injuries, and require unique solutions. They are American military heroes who have spent more than twenty years fighting the Global War on Terror (GWOT) all over the world. Their individual and collective accomplishments are legendary-as they deserve to be. Memoirs and histories have been written about them. Movies and television shows have been made celebrating their deeds.
The general public typically regards them as elite, brave, thrilling, sexy. They are held in awe by many. People admire them and want to be associated...
