The case of Sgt. Robert Bales has sparked debate about whether the Army failed in detecting a soldier's mental instability or pushed him too far. The Army is reviewing all its mental health programs and its screening process in light of the March 11 shooting spree in two slumbering Afghan villages that killed families, including nine children.
For some Americans, Bales is the epitome of a soldier afflicted by war's psychological wounds, pushed by the Army beyond his limits.
Bales' attorney says he does not know if his client suffered from PTSD but his initial statements appear to be building a possible defense around the argument that the horrific crime was the result of a 10-year military veteran sent back to a war zone for a fourth time after being traumatized.
Mental health professionals say it's reasonable to consider PTSD but it was likely not the sole factor that sent the 38-year-old father from Washington state over the edge. Still, there is much that is not known about the psychological wounds of war and how they can manifest themselves, and even less is known about the impact of multiple deployments.
Military officials say they have to rely on their mental health experts to decide whether someone is mentally fit to go back into war, and they cannot make a blanket policy of not redeploying troops diagnosed with PTSD. The provider makes a recommendation, but the ultimate decision to deploy a soldier rests with the unit commander.
Army Secretary John McHugh told Congress this week that "we have in the military writ large over 50,000 folks in uniform who have had at least four deployments." Some have served double-digit deployments, where they witnessed traumatic events.
"People do not understand that you can be treated for PTSD," said Dr. Heidi Kraft, who cared for Marines in Iraq in 2004 as a Navy combat psychologist. "It's a matter of turning a traumatic memory into just that a memory rather than something that haunts you.
"You can't say the person hasn't live through trauma, but symptoms can go completely into remission, where a person is very functional and in fact emerges from treatment better or more resilient. There is the misconception out there that if you have this diagnosis, you will always be disabled, and that's just not true."
It also depends on the severity of the PTSD, which can last anywhere from months to years.
Some troops treated for PTSD yearn to return to the battlefield where they feel more comfortable surrounded by their fellow troops and on a mission than in the unsettling quiet of their home life, mental health professionals say.
But Bales' attorney said that was not the case with his client.
John Henry Browne of Seattle said Bales had suffered injuries during his deployments, including a serious foot injury and head trauma and did not want to go on a fourth tour.
Military officials insist that Bales had been properly screened and declared fit for combat.
Army officials say soldiers sent to war may be checked up to five times, including before being deployed, during combat, once they return home, and six months and a year later. The Army screens soldiers for depression and PTSD, asking questions to find out about any social stressors, sleep disruption and other problems. Those who are detected as having problems go on to a second phase of screening.
Officials say, however, that no test is considered diagnostically definitive for mental illness in general or PTSD in particular.
Critics say the Army has a history of bandaging the problem and rushing troops back into combat by loading them up on prescription drugs. Military courts also do not recognize PTSD as a legitimate defense, said attorney Geoffrey Nathan, who has represented a number of court-martialed troops.
"They're still in a state of denial as to what combat soldiers go through in the field of battle," Nathan said.
The Army says it's committed to the health of the force, pointing out it has invested $710 million in behavioral health care and doubled the number of mental health workers since 2007.
"The Army has a robust policy to return soldiers who are fit for duty to combat units as soon as possible," said Army spokesman George Wright. "If a soldier has a broken leg, and he is healed, and fully capable of conducting the mission, he's eligible to return to duty. It's the same when qualified medical doctors, psychologists or psychiatrists determine a soldier suffering from a behavioral health disorder is healed. If he displays the signs that he's fully capable of accomplishing the mission as a solider, he'll be returned to duty."
Treatment can result in cure for some patients with PTSD, but more often results in improvement in symptoms and functioning, not a complete cure, according to the Army. PTSD can recur after treatment on exposure to other traumatic events or stressors. According to some studies, up to 80 percent of people with PTSD also suffer from another psychiatric disorder, making it challenging to make an accurate diagnosis.
The Army says its doctors look at a soldier's current clinical condition and rely heavily on the soldier telling the provider whether symptoms have subsided. The Army says it recognizes that deploying a soldier who is not medically ready puts both the individual and unit at risk.
PTSD is a condition that results from experiencing or seeing a traumatic event, whether it's being in a car crash or witnessing a battlefield casualty.
Browne said a fellow soldier's leg had been blown off days before the rampage and Bales had seen the wounds. A U.S. defense official said it is likely that a soldier from Bales' unit suffered a leg wound a day or two before the March 11 shootings, but military officials have no evidence that this has any connection to the massacre.
Bales also remembers very little or nothing from the time the military believes he went on the rampage, according to his attorney.
Not remembering a traumatic event or avoiding the memory is a classic symptom of PTSD, along with recurrent nightmares, flashbacks, irritability and feeling distant from other people.
But mental health experts believe other factors were at play. Bales' personal history shows he had a past assault case involving a casino bouncer that required anger management classes. Another assault allegation involved a woman and her boyfriend outside a bowling alley but ultimately didn't result in charges. He also had financial troubles.
Those who suffer from PTSD are prone to acting out, according to the Department of Veterans Affairs National Center for PTSD. But the violent behavior is usually against family members or fellow troops, not strangers, mental health professionals say.
Dr. Harry Croft, a San Antonio, Texas, psychiatrist who has diagnosed 7,000 veterans with PTSD for the Veterans Affairs Department and written the book "I Always Sit With My Back to The Wall" about PTSD said the case has set back years of work to erase the perception that veterans are walking time bombs who can go off without warning. Veteran advocates point to one tabloid headline labeling the then-unidentified suspect "Sergeant Psycho."
That stereotype, they say, has caused employers to shy away from hiring veterans returning from war and steered singles away from getting involved in relationships with them.
"Even the most severe cases of PTSD alone would not have caused such a heinous act like this," Croft said. "Something else was definitely going on, most probably severe depression, psychosis, substance abuse or he received some terrible news from home that pushed him over the edge."
Associated Press Chief Medical Writer Marilynn Marchione in Milwaukee, and AP writers Robert Burns and Donna Cassata in Washington, D.C., contributed to this report.