Study: Child Sexual Abuse Drops 40 Percent Nationwide
Kate McCann, Associated Press- 2/13/2004

CONCORD, N.H. -- A University of New Hampshire study says the number of children suffering from child abuse declined 40 percent from 1992 to 2000. Child protective agencies from most of the 50 states and the District of Columbia provided the numbers of substantiated abuse cases for the study, which shows a drop from 150,000 cases in 1992 to 89,500 in 2000.
     But critics caution the numbers may not be significant, by citing cases where allegations of abuse turned out to be false, or arguing that fewer victims are coming forward. The co-author of the study, David Finkelhor, says there are other indicators to validate his findings, such as parallel declines of teen pregnancies, teen suicides and teen runaways. "All of those things can be the more severe consequences of kids getting abused," Finkelhor said. Prosecutors also are incarcerating more pedophiles, Finkelhor said, and public education about the importance of reporting abuse is on the rise.
     The study, published by the U.S. Department of Justice and co-authored by UNH researcher Lisa Jones, has attracted little publicity, he said. "I think people are reluctant to talk about it because they think it might be a mirage," Finkelhor said. "Our conclusion is that the decline is real, and based on strong pieces of evidence."
     Finkelhor has other theories, which he said lack concrete evidence but he believes contributed to the reported decline. One is a change in the sexual climate of America. The sexual abuse scandal in the Catholic Church is a reflection of this shift in sexual attitudes, he said. Although the scandal didn't explode in the media until the 1990s, Finkelhor notes that most of the abuse allegations were decades old and not of present day. "The profile seems to be people who grew up in the kind of repressed 1950s and suddenly found themselves in the middle of this new swirling revolution in the 1960s and 70s where traditional losses of morality were being questioned," he said. More psychiatric medication to alleviate depression and a drop in unemployment during the economic boom of the 1990s also might be factors, he said.
     But these findings should in no way alleviate public concern for child sexual abuse, Finkelhor said. "Some people are afraid that if this gets too much publicity somehow policy makers will declare the problem is fixed and not be concerned about it," he said. "This is a big problem; we need to talk about it and see what's working, so we can do more of it," he said.

Psychiatrist Says Prozac Shooter Was Not Insane
Suzette Hackney, Detroit Free Press- 2/13/2004

A University of Michigan psychiatrist testified Wednesday that the man accused of fatally shooting two men after a bar brawl over a pool game was sane at the time of the incident. Dr. Phillip Margolis, professor emeritus for U-M's Psychiatry Department, said Christopher Bernaiche was in mental control when he shot up Drinks Saloon in Gibraltar in December 2002. Two men died in the shooting, and three others were wounded.
     Bernaiche is on trial in Wayne County Circuit Court, charged with two counts of first-degree murder and three counts of assault with intent to murder. Police and prosecutors said Bernaiche, 27, was wagering $20 a game in billiards and lost. He began to argue with bar patrons and employees and was tossed out. Bernaiche told police and numerous psychiatrists that he returned to the bar with a gun and began shooting. "Cognitively, he was alert and knew exactly what he was doing," Margolis said of Bernaiche. "He said to me that there was probably a certain amount of revenge in this, that he felt vengeful."
     Last week, Dr. Peter Breggin, an Ithaca, N.Y.-based expert psychiatrist on the subject of antidepressants, testified that Bernaiche was intoxicated on Prozac, and suffered from a mental illness caused by the drug. But Margolis, who has practiced psychiatry since 1953, said Bernaiche's actions before and after the shooting, such as concealing the gun, fleeing the scene, and confessing to police that he "only did it because they beat" him showed that he was able to distinguish between right and wrong. Margolis interviewed Bernaiche last December, nearly a year after the incident. Margolis said Bernaiche provided vivid details of the shooting and previous problems. Margolis testified that Bernaiche said he had a problem with alcohol and was drinking daily leading up to the shooting. He told the doctor he was taking Vicodin recreationally, and took a pill the night of the shooting to get high. Bernaiche also reportedly told Margolis that he had several beers and vodka drinks at the Gibraltar bar as he played pool. Police say Bernaiche did not appear intoxicated when he was arrested after the shooting. His blood alcohol level was not tested.
     Bernaiche's defense, legal insanity due to a Prozac-induced rage, is new to Michigan. Bernaiche began taking Prozac in October 2002. The dosage was doubled from 20 to 40 milligrams five days before the shooting. Prozac and other drugs are in a class known as selective serotonin reuptake inhibitors, or SSRIs. Prozac is the most widely used of these drugs. The group also includes the brand names Paxil, Zoloft and Luvox. Testimony continues today in Judge Deborah Thomas' courtroom.



Abuse of Cold Medicine on the Rise
Bonnie Miller Rubin, Chicago Tribune- 2/13/2004

Emergency room physicians are reporting a sharp increase in teens abusing non-prescription cough and cold medicines, which are back in vogue as recreational drugs because the products are accessible and easier to take than ever before. Users call it "skittles," "triple Cs" (for Coricidin HBP Cough & Cold tablets) or "robo-tripping" to describe its hallucinogenic effects. Medical personnel are calling it an epidemic.
      The latest concerns have caused some drugstore chains to limit purchases. But the efforts don't go far enough, say many critics, who are urging that all such products be sold strictly from behind the counter. "It's not illegal to purchase. It's not even illegal to take in large quantities. It's just dangerous and foolish and that is what is scaring everybody," said Dr. Charles Nozicka, director of pediatric emergency medicine at St. Alexius Medical Center in Hoffman Estates. Nozicka estimates he has seen about 30 cold medicine-related overdoses in the last year.
      While students have been guzzling cough syrup for years, this is a relatively new phenomenon. Sweet syrups would contain ingredients that cause vomiting before reaching doses large enough to hallucinate. Tablets don't have that effect. The key ingredient is DXM, a cough suppressant that replaced opiates in the 1970s and can be found in more than 120 products, all safe when used as directed. But taking DXM in large quantities can cause slurred speech, tremors, seizures and even death. Because the product is at every pharmacy, the dangers are easy to dismiss, said experts.
      While no national agency tracks fatalities, at least five have been attributed to cold medicines during the last year, including one in September at Illinois State University. More indicative of a growing problem: U.S. poison-control centers logged some 3,200 calls related to the substance in 2003--twice the number as in 2001. Locally, the Illinois Poison Center got 160 calls last year--an increase of 26 percent since 2001. "It wasn't something we really noticed before 2001," said Dr. Michael Wahl, medical director of the Illinois Poison Center. To raise awareness, the Chicago office of the U.S. Drug Enforcement Administration issued a parental advisory last week, citing a "recent escalation" in area DXM abuse. In addition, the American Medical Association voted in December to pursue national restrictions on the products.
      Dr. Tim Erickson, director of clinical toxicology at the University of Illinois Medical Center at Chicago, realized that this was quickly becoming the drug of choice when he searched for Coricidin and found stores were cleaned out. "The word is out," Erickson said. "It has totally permeated the adolescent population--especially in the suburbs."
      Mike, 17, first heard about DXM from friends at his northwest suburban high school. "The main reason I did it every day is because it was just so available," said the senior, who asked that his last name not be used. "I didn't need a connection. ... I could steal it. I could get it for free."
      The addiction remains stubbornly under the radar. Most cases don't end up in an emergency room. Even if they do, personnel don't regularly test for legal substances. And while marijuana and Ecstasy are still more popular, those substances usually arouse parental suspicion. No such alarms go off for cold products--especially in the winter. "Kids can abuse a long time before adults suspect a problem, said Dr. Louis Kraus, director of child and adolescent psychiatry at Rush University Medical Center, who brought the issue to the AMA. "Even physicians are basically in the dark about this ... but it's at every high school on the North Shore," said Kraus, who has a private practice in Deerfield.
      While Mike was no stranger to pharmaceuticals, Coricidin quickly zoomed to the top of the list. At the lower doses, he would experience a pleasant euphoria "like a good body buzz." Most of the time, though, he would opt for about 20 of the red pills--or a few more than a box--which delivered something far more "intense." (Recommended dose: one every six hours). Despite using the drug every day for about five months, Mike said he never OD'd. "But I was shaking a lot ... and I was at the point where I was stealing it all the time. ... My parents knew about a lot of stuff, but they were pretty clueless about this." Eventually, his grades dropped and his parents "put two and two together" and brought him to Alexian Brothers Behavioral Health Center, as well as Hazelden Clinic near St. Paul, for substance abuse treatment. After three relapses, he said that he has been clean for two months and back at school, where he's just trying to get through his senior year.
      Coricidin's manufacturer, Schering-Plough HealthCare Products, has stepped up efforts in recent months, including working with national retailers and anti-drug organizations, according to Mary Fran Faraji, spokeswoman for the New Jersey-based drugmaker. Last month, Walgreens nationwide began limiting the sale of Coricidin HBP to three packages, with other chains--such as Osco and Dominick's--following suit. They leave it to the discretion of store managers whether to clamp down further. But until all stores keep it out of reach, most health-care professionals won't be satisfied. "It's a joke," Kraus said. "Kids who are shoplifting don't care about how much they can buy. Until it's behind the counter, we're going to continue to have an increasing problem."

Methadone Abuse on the Rise
Rick Jervis, Chicago Tribune- 2/13/2004

The death of an Alsip high school football player that initially stumped police and family was caused by an overdose of a painkiller that is increasingly being abused across the country, experts say. James Van Slette, 14, who was found dead in his home in October, overdosed on methadone, a narcotic opiate long used to combat heroin addiction and alleviate chronic pain, according to the Cook County medical examiner's office. Alsip detectives still are trying to determine how Van Slette, a freshman at Eisenhower High School in Blue Island, got the methadone and how widespread its use may be among area teens.
      Methadone abuse has been growing so rapidly in the past few years that officials from the Drug Enforcement Administration, Department of Health and Human Services and other federal agencies met last week in New York to exchange information and tactics. Part of the problem, officials said, is some states may not notice the problem. "It's definitely a challenge trying to collect this data, analyze it, and raise awareness," said Robert Lubran, a director with the Drug Abuse Warning Network. "I don't think the general public has the full picture of how many deaths are related to methadone and other opiates."
      The death of a Barrington teenager from a methadone overdose in 2002 was the subject of a Lake County trial this week. In the Chicago area, federal statistics indicate that methadone-related deaths climbed from 41 in 2001 to 53 in 2002, the last year for which figures were available. A number of states are recording increases in methadone-related deaths, including Florida, where they rose from 357 in 2001 to 556 in 2002--more than those caused by any other drug, according to a National Drug Intelligence Center bulletin. The federal drug network calculates that emergency room trips involving methadone increased from 3,832 in 1997 to 11,709 in 2002, but there are no national figures for methadone-related deaths.
      Methadone usually is taken in liquid form as way of fighting heroin addiction. The opiate lessens the pain of withdrawing from heroin and is not considered easily addictive. Doctors also prescribe methadone in wafer or pill forms to treat chronic pain, such as that associated with cancer and arthritis. There has been a steep surge in the number of prescriptions for methadone. According to DEA statistics, methadone distributed by hospitals and doctors climbed from 692,675 grams in 1998 to 1.9 million grams in 2001. Officials said they fear prescribed doses, more than clinic-supplied methadone, are trickling into the streets.
      Clinical workers confirm that a street market has evolved for methadone, which at $15 or $20 a bottle is cheaper than a $100-a-day heroin habit. "It does appear to be more available on the street than it used to be," said Larry Dunbar, vice president for clinical services at the South Suburban Council on Alcoholism and Substance Abuse. "Suburban communities are seeing more heroin use. But heroin is expensive. When they can't get heroin they get what they can, and methadone is a good replacement." Two-ounce bottles of methadone given to addicts at treatment centers typically are diluted with water to reduce their street value, said Dr. Ernest Rose, a heroin-addiction specialist. Pills are becoming increasingly popular, he said. "They have a lot higher market value," he said. "What you see is a large population from the suburbs coming into the city to buy methadone off the street."
      Dr. Usha Malkerneker, a medical director at a heroin addiction center in Hazel Crest, said she has seen street methadone circulating among patients. "One person came in recently who had been taking it every day for the past six months," she said. "She was buying it on the street." Still, methadone hovers under the radar of many law enforcement agencies.
      Alsip police said they were surprised when the coroner's toxicology report showed methadone killed Van Slette. "Blew me out of the water," Alsip Deputy Chief Pat McDonald said. "We've never really come across it. This boy was a good kid. It's very unfortunate." Detectives were interviewing Van Slette's classmates and friends and are awaiting the full report from the medical examiner's office to try to determine where the methadone came from, McDonald said. Van Slette played middle linebacker at Eisenhower and ran track. His mother, Donna Van Slette, said that on Oct. 26 she went to a youth football league party with her son and husband. That night, the youth woke up about 3:30 a.m., crying her name, she said. His skin felt warm, and he was vomiting. Thinking he had the flu, his parents made him stay home from school the next day. His father came home that afternoon and found him unresponsive. Family and friends initially thought he might have died as a result of a concussion he received playing football. Donna Van Slette said she does not know where her son may have gotten methadone. "It's caught the whole family off guard," she said. "This is a tragic accident. He made a mistake, but he wasn't a bad person."
      What makes methadone so lethal is its slow yet powerful sedation, which can lull first-time users into taking too much, said Dr. Jerrold Leikin, director of medical toxicology at Evanston Northwestern Health Care. Even a small amount can be damaging. As methadone attaches itself to the brain's opioid receptors, triggering soothing effects, the heart slows, body temperature drops and breathing slows, then ceases. "As little as 10 milligrams can be fatal," Leikin said.
      Federal officials now face a quandary: how to curb the abuse of methadone without limiting its uses for pain patients. "There is a concern," said Mark Parrino, president of the American Association for the Treatment of Opioid Dependence. "Or else every federal agency would not have gathered to address it."

Psychiatric Patient Tells of Ordeal in Treatment
Hal Dardick, Chicago Tribune- 2/13/2004

When Elizabeth Gale sought psychiatric treatment in 1986, she suffered from depression, the most common of psychiatric illnesses. But Dr. Bennett Braun and his colleagues convinced her that her family indoctrinated her as a child so she would make babies for sacrifice in a satanic cult, Gale charged in a malpractice suit she settled Wednesday for $7.5 million. The therapists, she alleged, told her she needed their help to recover memories hidden beneath layers of rare multiple personalities that she had developed as a psychic guard against her childhood trauma. Braun's attorney Martin Kanofsky said his client denies the allegations and declined to comment further.
      On Thursday, Gale talked about how over an 11-year period she spent more than 2,000 days in psychiatric hospitals and cut off contact with her family. She said she changed her name three times, underwent sterilization and fled town to escape detection by the cult. She also gave up her job as a legal secretary at a Chicago law firm, quit her undergraduate business studies at DePaul University and distanced herself from friends. "I never thought I'd want to go back in my life," Gale said. "But I would like to go back to the day in my life I stepped into that hospital and say, `No.' It's a tragedy I can't reverse." Gale, 51, is living in the northwest suburbs, mending fences with family members and undergoing traditional psychiatric treatment. She has received her degree. "It will never be the same," she said. "There are some things you can't get back."
      Gale's attorney Todd Smith said that under the settlement, entered Wednesday in Cook County Circuit Court, Rush North Shore Medical Center, where Braun was director of the dissociative disorders program, will pay $3.6 million. Psychologist Roberta Sachs will pay $3.1 million, and a corporation affiliated with Braun will pay $500,000. Dr. Corydon Hammond will pay $175,000, and Rush University Medical Center must pay $150,000. No wrongdoing was admitted by the hospitals, the doctors or the psychologist. Hammond's attorney Scott Thomas declined comment.
      Sachs' attorney, Richard Donohue, said the payment by his client was so high because "she's the one who had insurance coverage." He described her involvement in Gale's treatment as "small potatoes," a characterization with which Gale took issue, saying "she ran the program." "As far as the hospital and its administration knew, Dr. Braun and his team, who were considered national experts, were using accepted treatment at that time," said Rush attorney Mary Ellen Busch. "That treatment is now undergoing scrutiny and is becoming increasingly controversial." Braun and his associates specialized in treating multiple personality cases with recovered memory therapy, which was popular in the 1980s and early 1990s but later came under intense criticism.
      Elizabeth Loftus, professor of psychology and criminology at University of California, Irvine and a well-known debunker of repressed memory theories, said Braun "was a major figure in the multiple personality world" that espoused repressed memory theory. There's "a severe dent" in repressed memory theory "because of the many, many patients who have retracted their claims and know now they were false," she said. "A lot of the hospital dissociative units have shut down."
      In 1997, west suburban resident Patricia Burgus received a $10.5 million settlement in a suit filed against the hospital, then known as Rush-Presbyterian-St. Luke's, and two therapists, including Braun. Burgus and her sons were hospitalized at Rush in the late 1980s. Braun later sued his insurance company for allegedly settling the case without his consent. Burgus, under Braun's care, said she came to believe she had more than 300 personalities and had cannibalized children as part of a satanic cult.
      Rush ended its relationships with Braun and Sachs, and in 1999 Illinois suspended Braun's medical license for two years. At the end of that period, he was barred for five years from treating dissociative identity disorders, including multiple personality. A spokesman for the Montana board of medical examiners said Braun was issued a medical license in that state in June. Sachs is believed to be living in Maryland.
      Gale said she was feeling suicidal in 1986 when she sought treatment. She said she was referred to Braun and was hospitalized in September of that year and remained there until November 1990. Between then and 1997, during which she was under Braun's care, Gale said she was hospitalized 17 other times. She was told her parents and four siblings were part of a cult and she was raised as a "breeder" to produce babies for pornography and sexual abuse, among other things, before they were sacrificed, she said. In 1991, she underwent a tubal ligation with Braun's support, she said. "I didn't want to have any more children," said Gale, who has never been pregnant. "I didn't want to offer them up to the cult."

Studies: Alcohol Damages Fetal Brain Cells
Associated Press, 2/14/2004

SEATTLE -- Just two cocktails consumed by a pregnant woman may be enough to kill some of the developing brain cells in the unborn child, leading to neurological problems that can haunt a person for a lifetime, new studies suggest.
Dr. John W. Olney, a brain researcher at Washington University in St. Louis, said his studies show that alcohol can cause nerve cells in the developing brain to commit suicide.
And, based on animal studies, it doesn't take much alcohol to have this effect, Olney reported Friday at the national meeting of the American Association for the Advancement of Science.
Two cocktails, in most women, is enough to elevate alcohol levels in the blood to 0.07 percent, he said. The animal studies show that in unborn mice this concentration is enough to kill developing brain cells.
``That amount of alcohol would cause a state of intoxication just under the legal limit, which is 0.08 percent in most states,'' he said.
A single glass of wine may not be a problem, but ``if one glass leads to another, and then another on the same day, that is a different matter'' because it keeps the alcohol concentration at a toxic level long enough to be damaging. He said studies in mice show that just one hour at 0.07 percent is enough to kill fetal neurons.
Olney said his studies show that when neurons in the developing brain fail to make new synaptic connections, they are programed to commit suicide, a process known as apoptosis. Making the synaptic connections, part of building a network in the brain, begins during the sixth month of gestation in humans and continues for several years after birth.
Alcohol interferes with making the new synaptic connections, causing the cells to die. And alcohol is not the only chemical that has this effect.
Olney said his mouse studies show that medical anesthetics can also cause the death of fetal neurons. So can some of the so-called ``party drugs,'' he said.
As a result, Olney recommended that pregnant women should avoid exposing their unborn to general anesthetics whenever possible, even if it means delaying some surgeries until after delivery. He said the short-term use of painkilling drugs during labor do not put the fetal brain at risk.
In another study, Columbia University psychiatrist Ezra Susser said his research team has found evidence suggesting a link between a pregnant woman's exposure to lead and the development years later of schizophrenia in her children.
Susser said lead as a cause of some schizophrenia is still an unproven theory. But he said a study of blood samples taken from pregnant women in Oakland, Calif., between 1959 and 1966 shows that children whose mothers had higher levels of lead in the blood were about twice as likely to become schizophrenic later in life.
New studies on the effect of lead on the unborn child are now under way in other cities, and proof of his theory must await those results.
The blood samples from the Oakland mothers were taken before unleaded gasoline became the norm, and consequently, pregnant women were exposed to higher levels of lead in the atmosphere.
But Susser said that his studies suggest all levels of lead exposure are dangerous for unborn children.
``There is no level at which lead is safe,'' he said. ``We get to lower and lower points in our studies and there seems to be no level that will not have a prenatal effect.''

PTSD: The Permanent Scars of Iraq
Sara Corbett, New York Times Magazine- 2/15/2004

Robert Shrode can't sleep. At night, in the fly-speck town of Guthrie, Ky., in the rented farmhouse he shares with his 20-year-old wife, Debra, he surfs the Internet, roams the house. He lies down and gets up again. He drinks a beer and stares out the window at the black fields beyond. Hours pass. He can't sleep. Before the war, he could have six beers and sleep like a baby, but now that works against him. Drinking may help get his head to the pillow, but it also ratchets up the nightmares. For a while, he sweated out his bad dreams on the living-room couch, and it drove Debra crazy. She would come down from the bedroom, touch his shoulder, ask what the problem was. Shrode would just turn his back to her and not say a word. Now she knows better than to ask, though occasionally when the silence between them gets too deep, she'll put it out there, What're you thinking about? ''Iraq,'' he'll say. And then the silence falls again.
      He pops Ambien to coax some sleep. The results are mixed. On the advice of his doctors, he is taking three different pills for pain, a pill for swelling and another pill for depression. There are days when he is unrecognizable to himself, a guy who a few years ago was a party-loving bartender at a Mississippi casino and who is now 29 and engaged in what can feel like a never-ending battle to see his own future brightly.
      The only person who understands him is his buddy Brent Bricklin, a restless, dark-haired 22-year-old and fellow Army specialist in the 101st Airborne Division, who is also home after serving in Iraq. Most mornings, Shrode picks up Bricklin at Fort Campbell, the sprawling base that straddles the Kentucky-Tennessee state line where both men are stationed, and they go driving. It's always more or less the same. They drive through the buttressed gates of the base, patrolled by armed National Guardsmen, and turn onto Fort Campbell Boulevard, passing the check-cashing outfits, the strip clubs and gun-and-ammo shops that, during peacetime anyway, boom with military business.
      Shrode sometimes jokes that he loves his Chevy Tahoe more than his wife, and it's half true. The Tahoe is a big upholstered bubble, a place where he can watch the world drift by harmlessly. Inside it, he shares more with Bricklin than he does with Debra, whom he met at a nightclub in 2002 and married three months before going to war. ''I can talk to him -- I can't talk to my wife,'' Shrode says. ''But 30 seconds with him, and I feel better.'' Not far from the base, they pass a pint-size Kia driving in the next lane. Someone has used soap to write a self-congratulatory ''Back From Iraq'' in large letters across the rear window. This being December, the only soldiers back from Iraq are ones sent home because of expired enlistments or for medical reasons or those on their way to being transferred elsewhere. The bulk of the division -- some 20,000 local soldiers -- remains at war. Shrode and Bricklin stare down at the Kia. ''Dumb idiot,'' Bricklin says. Shrode says nothing.
      It's been nearly six months since Shrode and Bricklin arrived home from Iraq. Shrode lost most of his right arm, which was amputated just below the elbow in a Baghdad field hospital. Even healed, his face is pitted with purple shrapnel scars the size of raindrops. Bricklin, a broad-shouldered former competitive swimmer who came home honeycombed with shrapnel, bears larger, raw-looking scars from his thigh to his neck. Both men have significant hearing loss, cocking their heads like a couple of old-timers in order to grasp what's said. They are plagued by headaches and are convinced they've had some memory loss. Between them, they've had nine operations since getting, as they like to say, ''blown up'' in Iraq. Shrode, who is shorter and stockier than Bricklin and speaks with a soft Alabama accent, still visits the base hospital five days a week for occupational therapy. Once a month, he sees a military therapist. He has tried, without luck, to persuade Bricklin to get individual counseling too. ''He says I took it harder than I say I do,'' Bricklin says with a deflective smile. ''He did,'' Shrode says. ''He's says I'm messed up in the head.'' ''You are,'' Shrode says earnestly. It's a subject Bricklin doesn't want to discuss. He playfully jabs a finger near the stump of his friend's arm: ''How much feeling you got left in this thing, anyway? Let's find out.''
     Both men say they feel more vulnerable since coming back from war. When someone recently dropped a tray in the hospital cafeteria, Shrode dove, horror-struck, beneath the table. A crackling summer thunderstorm sent Bricklin into a panic, convinced he was caught in the back blast of a grenade again. Both say they have frequent nightmares. And then there's something less tangible, a visceral undercurrent of anger that makes them walk around feeling ready to explode. ''I can go from being happy-go-lucky and joking to having someone's throat in my hand, like that,'' Bricklin says, snapping his fingers. Shrode nods. ''My fuse is short,'' he says. ''It's real short.''
      Shrode and Bricklin are 2 of the 2,600 United States soldiers wounded in action in Iraq as of early this month, according to the Department of Defense. The basics of their stories are hauntingly familiar: just after midnight one night in June, a rocket-propelled grenade shrieked out of nowhere and hit their Humvee, which sat parked at a police station in the Baathist city of Fallujah. What was reported in the news bore the standard sterility: ''One soldier killed; five others injured.'' What wasn't said was that Branden Oberleitner, the private who died standing almost shoulder to shoulder with Shrode, was a car buff who once planned to become a firefighter or that he was killed two weeks shy of his 21st birthday. It didn't say that his blood was all over the road.
      But for whatever societal void the dead disappear into, it is the wounded who must live with the confounding mix of anonymity and exposure wrought by surviving a war. On and off the Army base, Shrode is approached by strangers who size up his military haircut and missing arm and feel compelled to heap on the thanks for serving in Iraq. They all but ignore Bricklin, who is often with him but whose injuries remain hidden. Shrode finds the situation reliably awkward, sensing a whiff of pity riding on the backside of flattery. The people who open doors for him, he says, make him feel handicapped. And then there are those whose gazes follow him wordlessly as he makes his way down the buffet line at the China King restaurant near the base -- drawn, it would seem, to the spectacle of a one-armed man working to load his plate. The discomfort feels irresolvable. ''Somebody stares at it, I get mad at them,'' Shrode says. ''Somebody looks away, and I get mad at that.''
      For both soldiers, the tension between themselves and the rest of the world builds up quickly and with no real outlet. Bricklin has had one run-in with the police and says that he's been a jerk ''to anyone who didn't go'' to war. Even when someone shows concern for their well-being -- when Debra touches her husband's shoulder or a stranger flashes a kindly smile -- the effect can be abrasive. One day, as Shrode was walking down a hospital hallway, a civilian passing by happened to toss out an innocent ''Howyadoin','' which somehow, in that moment, became the last straw. ''Ninety-nine percent of the time, I tell them what they want to hear,'' Shrode says. But in this instance he couldn't help blurting out a truth that was becoming more evident each day. ''Buddy,'' he said, ''I'm going to hurt the rest of my life.''
      Every other Tuesday, Shrode drives over to Fort Campbell's mental-health building to attend a support-group meeting for injured soldiers. Before going to Iraq, before being wounded, he wouldn't have been caught dead doing something like this. Support groups were the stuff of Oprah -- helpful for others, maybe, but not for him. Given the uncomfortable silence before a session begins, it is clear that Shrode is not the only squeamish one. The soldiers -- usually anywhere between 5 and 15 of them -- sit in a circle of couches and chairs in the cramped linoleum-floored waiting room of the mental-health building, looking almost like a roomful of unusually clean-cut college kids gathering for a study group. Except that one walks with a cane. Several others have burn sleeves covering their arms. A woman with a bobbed haircut wears an arm splint. There's a guy -- an Apache helicopter pilot -- who has balance problems. His neighbor, a muscled young corporal, winces as he takes a seat. When they make chitchat, it tends to be about skin grafts and medication and how there aren't enough handicapped parking spaces on base. Occasionally, some will compare scars, hiking up pants and shirts and inspecting the wreckage of someone else's limb or torso. ''Hey, yours is growing hair back!'' one soldier says to another. ''That's pretty good.''
      For every broken body in this room, there are hundreds more confined to hospital beds across the country and hundreds more again who, by choice or by circumstance, are gutting out the effects of their injuries without the help of peers or mental-health counselors. It has been suggested that the wounded are the hidden casualties of the Iraq war, stranded somewhere between our grief for the dead and a wartime patriotism best stirred by the belief that our troops are both productive and healthy. Thanks to the lifesaving properties of body armor and largely impenetrable Kevlar helmets, combined with highly advanced battlefield medicine, more soldiers are surviving explosions and gunfire than in previous wars. The downside of this is that the injury rate in Iraq is high: an average of nine soldiers have been injured per day. The pace shows little sign of slowing, which means it's possible we will bring home another 1,500 wounded before the start of summer. Some military experts worry that in the next four months -- as the U.S. rotates roughly 110,000 new troops into Iraq, many of them reservists and National Guardsmen with less combat training than the full-time soldiers they are replacing -- injury rates could climb even higher.
      The government's reports on the wounded can be confusing. In early February, the Department of Defense Web site listed 2,600 soldiers as wounded in action in Iraq and another 403 as injured in ''nonhostile'' incidents like helicopter or motor-vehicle accidents. Meanwhile, the Army Surgeon General's office said that only 804 soldiers have been evacuated with battle wounds and that over 2,800 have been injured accidentally. In addition, the Surgeon General's office reported that another 5,184 soldiers have been evacuated from the theater for other medical reasons, which could include anything from kidney stones to nervous breakdowns. To date, 569 of these have qualified as psychiatric casualties.
      Although many of the soldiers who attend the support group at Fort Campbell have escaped enemy fire, their injuries reflect the full spectrum of what can go wrong during war: Sgt. Jenni McKinley had her right hand crushed when her Humvee blew a tire and flipped over on a sandy road outside of Baghdad. Chief Warrant Officers Emanuel Pierre and Stuart Contant were pilots whose Apache helicopter reportedly malfunctioned and then crashed in Afghanistan, requiring them to spend months in the hospital and to endure multiple operations. There is a medic who is physically uninjured but tormented to the point of agony by memories of treating his wounded and dying colleagues. And then there is a quiet young private who comes because her hair is falling out and her fingers are numb and nobody seems able to tell her why.
      These soldiers generally are no less disabled than those who were hit by AK-47 fire. Sgt. Jeremy Gilbert, another medic, laments that he never made it into Iraq at all, since a week before the invasion, a Kuwaiti civilian driving 90 miles per hour plowed into Gilbert's Humvee, shattering the soldier's right leg and pelvis and relegating him to a wheelchair for five months. ''There's nothing glamorous about the way I got hurt,'' says Gilbert, who wept in frustration as he watched the first live footage of the Army's invasion of Iraq from a bed at Walter Reed Army Medical Center in Washington. ''But it sure has trashed my life.''
      Operating with a blend of military toughness and quiet empathy, the injured soldiers' support group -- believed to be the first of its kind on an Army base -- has taken on everything from fractured self images and faltering marriages to traumatic memories of Iraq and the pervading question of what each soldier's future looks like in the wake of both war and injury. Yet there is little that's 12-step about it. You won't find group hugs or even metaphorical handholding here. Nor is there any second-guessing whether it was worth it to go to war in the first place. In the context of the Army's rigid hierarchy and low tolerance for weakness, the power of the support group, it seems, comes from its ability to listen.
      The first time I visited, in late November, conversation was dominated by one soldier, a newcomer who looked to be in his early 30's, with a spinal injury that had required some of his vertebrae to be fused together. As a result, his neck appeared stiff and unyielding; his back, ramrod straight. He spent the better part of an hour raging about various things that angered him, mainly the way his commanders were treating him and issues he had with his medical care. When he spoke, it was at a full shout, letting out a stream of emotion so potent and vituperative that it seemed his rigid body might launch right off the chair. The other soldiers listened, expressionless except for Brent Bricklin, who leaned back in his chair with a smirk, as if he wasn't buying a word of it. It wasn't until the newcomer mentioned that he wished he were back in Iraq that anybody else chimed in. ''I miss it, too,'' another soldier said. ''At least there was a purpose.'' ''I wish I was in Iraq because my buddies are there,'' Robert Shrode offered. Heads in the group began to nod. The atmosphere seemed to lighten. But then the newcomer -- or Angry Neck Man, as some of the others would later call him -- charged headlong into another furious rant.
      A while later, sitting with Terry James, the easygoing retired first sergeant who moderates the group and works as a counselor at Fort Campbell, I remarked upon how unnerving I found the soldier's anger, how potentially violent it seemed. James just laughed. ''That's how they all come to us,'' he said. ''Pretty much everyone starts out mad. Any other place in the military would've cut him off, wouldn't have let him get his anger out.'' The line between venting and sniveling, however, can be imperceptibly thin. One soldier's fury may set off another's, as was the case in a meeting where a soldier ran on too long, in Shrode's opinion, kvetching about a minor gunshot wound in his shoulder: ''He was whining and complaining and I said: 'Shut up. I'd love to be in your situation. There's a lot of people worse off than you and worse off than me.''' At another meeting, a soldier who had been run over by a truck complained to the group he hadn't received a Purple Heart -- the medal reserved for soldiers injured or killed in combat. ''I told him to get lost,'' says Shrode, who received a Purple Heart last summer. ''And then I got up and left.''
      A number of soldiers confess that they were initially put off by the concept of group therapy, figuring it was going to be ''a bunch of guys crying and wiping snot on their sleeves.'' Most insist they attend not for emotional release but rather to receive information -- about disability benefits or discharge procedures. The soldiers' questions often reflect a me-against-the-world mistrust of what's to come, an indistinct but entirely accurate perception that this country has failed veterans of past wars. The war will stay with them, they realize, but after a point the Army won't.
      For many, including Robert Shrode, the question is when and how to formalize their separation from the military. Everyone in the group is an active-duty soldier, though many say they are doing little more than showing up for morning formation these days -- either too consumed by pain and doctors' appointments or simply uninspired to work while their units are still in Iraq. Yet there is little that's light about what they face. In order to be medically discharged, soldiers must go before the Army Physical Evaluation Board, which assesses their injuries and then either approves or disapproves the discharge. Eventually they receive a ''disability rating'' from the Department of Veterans Affairs, which determines how much money they are eligible for. A soldier deemed ''100 percent disabled'' is granted a base payment of $2,239 monthly. (The payment can be supplemented depending on the severity of the injury.) Though the V.A. judges each case individually, an amputated arm generally gets you a 60 to 90 percent disability rating. Shrode has been told that his hearing loss and depression will likely further increase his rating.
      It's the promise of a new arm that keeps him in the Army. When I met him, Shrode was waiting to get a state-of-the-art prosthetic, worth $35,000 and paid for by the government. The Army had flown him several times to Walter Reed to work with its best occupational therapists, training the tiny reflexive muscles in his elbow so that they eventually could control the carbon-fiber myoelectric hand that was being custom-built for him in Nashville. If the new arm didn't work out well, Shrode faced a cruel choice: he could have his elbow amputated in order to be fitted with a different and more effective type of prosthetic. When it came to fake arms, though, he was hardly optimistic. In August, he had been given a low-tech prosthetic, with a hook where the hand should be, and while he had quickly proved to be a whiz at putting pegs into the pegboards they thrust at him at occupational therapy, he hated both the look and feel of it, preferring to master real-life tasks with his one good arm. He had proudly learned to lace and tie his boots and was working on figuring out how to cut a steak. When we went driving, Shrode smoked a cigarette with his left hand, ably piloting the Tahoe with one knee. In the meantime, his right arm -- or the piece of plastic that was supposed to pass for it -- rolled around neglected in the back seat.
     A tornado siren blasts, and Jenni McKinley rips up her pickup truck, hunting for a gas mask. A car backfires, and she dives for cover. The panic is instant and the charge for safety instinctive and ultimately embarrassing as she climbs to her feet again, bug-eyed and looking for snipers, instead finding the Kroger parking lot full of oblivious cart-pushing families. A person can come to doubt her sanity this way. Then there is the dead marine who visits her as she tries to sleep. A young guy, he can be angry, accusative, and sometimes he just shows up quietly and stares at her until she's jarred awake, heart racing -- another night's rest stolen away.
      McKinley is 27 and a career soldier, having logged eight years with the Army, and is hoping to stay until she has earned her military retirement benefits after 20 years of service. Off duty, she has a gentle manner, a dry wit and a penchant for good wines. On duty, she has worked hard to achieve the rank of sergeant, completing tours in Korea and Kosovo, where she led a small team of mostly men. As a female soldier, McKinley says she feels the pressure to constantly prove herself, to remain emotionally bulletproof. But Iraq really got to her. ''I didn't handle war the way I thought I was going to,'' she told me one night over dinner at a Red Lobster on a strip-malled stretch of road not far from Fort Campbell. ''I thought I was going to do my job, be strong. But three days into it, I broke down crying. The scuds were flying. We were waking up to the sounds of explosions over our heads. It was terrifying.'' Whatever fear she felt, nobody saw it: she ducked into an empty field tent to do her crying. Three days later, in 115-degree heat, McKinley's Humvee rolled over, pinning her beneath it and all but destroying her right hand.
      Since arriving back in the United States in April, McKinley has been told she suffers from post-traumatic stress disorder, which garnered recognition in the years following the Vietnam War and today is used to describe the most crippling psychological effects of trauma. The name may be new, but the concept isn't. Research on World War I veterans showed that even those who might be termed well adjusted still reported that they were quick to anger, forgetful, anxious and regularly suffering from headaches and dizziness. Traumatized World War II vets were commonly referred to as having ''battle fatigue.'' Today the military uses the term ''combat stress'' to describe a range of symptoms including anxiety, sleeplessness and depression, but post-traumatic stress disorder itself generally is diagnosed only when the symptoms become ''intrusive'' -- in other words, when they start to really mess up a soldier's or veteran's life.
      McKinley has a difficult time parsing the source of her post-traumatic stress disorder. Does it stem from the shock of the Humvee accident? Was it the flying scud missiles or the sirens that wailed nearly hourly early on in the war, signaling possible incoming chemical or biological weapons? Or maybe it was the marine who lay bleeding on the stretcher next to hers at a desert combat support hospital. He was younger than she was and had been shot in the face several times. As McKinley lay watching in a morphine haze, a doctor and team of nurses worked to stabilize him. Just as they moved on to examine her mangled hand, he flat-lined and the doctor rushed back to revive him. But the soldier flat-lined again. The doctor jump-started the marine's heart twice, three times, only to have it fail -- again and again -- until the nurses finally pried him off the soldier's body. After a time, McKinley boosted herself up and took a long look at the dead man's face -- maybe to honor him and maybe to learn something. She still doesn't know why.
      Her case of post-traumatic stress disorder most likely stems from the combination of these events. Researchers believe that the condition is not always connected to a specific incident and can, in fact, be spawned by repeated exposure to fear or by bearing witness to something violent or traumatic or by experiencing moral uncertainty connected to these things. Depending on the intangibles of a person's background and ability to either process or shut out stress, there are those who come through war relatively unscathed and those who don't. It's as if every psyche has a reservoir for trauma, and some fill faster than others -- each soldier's breaking point different from the next one's. And while many G.I.'s manage to hold it together during a deployment, the repression of emotion over time can lead to a tumultuous homecoming. Post-traumatic stress disorder is considered controllable but not curable, and often it will flare up years after the original trauma. In 1994, for example, Veterans of Foreign Wars officials noticed a significant spike in claims of post-traumatic stress disorder -- not from soldiers returning from Operation Desert Storm or Somalia but rather from World War II veterans whose nightmares were revved by the hoopla surrounding the 50th anniversary of D-Day.
      Since McKinley returned to the United States in April, the vision of the dead marine's face has sat in her mind like an elephant blocking the road. ''When I first got home, the nightmares were him basically calling me selfish, asking why didn't I help save him,'' she said, her voice so grave and quiet that it was nearly inaudible. ''And now it's changed to he's asking me why I didn't go with him.''
      McKinley has two children, ages 4 and 6, who live with her ex-husband 50 miles away in Nashville but spend weekends at her two-bedroom apartment close to Fort Campbell. With virtually no use of her right hand, she has struggled with the smallest of maternal tasks, from opening jars to cutting vegetables and carrying laundry. Before she began treatment for post-traumatic stress disorder, a child's simple request for apple juice could send her into a tailspin; her sleepless nights left her snappish, unloving. ''My husband would come pick the kids up on Sundays,'' she said, ''and before they'd get halfway home, I'd be calling on the cellphone, crying and asking if I could apologize to them for how I'd acted.''
      The low point came on the day she managed to change the sheets on her queen-size bed -- a task that, one-handed, became a two-hour ordeal. In the end, she was nothing short of triumphant, with a bed orderly enough to pass a military inspection. And then the children arrived, tumbling through the door as they always did, eventually settling down on McKinley's bed to watch TV as she cooked dinner. But sitting on the bed led to jumping on the bed, which in turn led to tearing off the sheets in an exuberant frenzy. McKinley became unhinged. ''I completely lost my mind on them,'' she said, sounding as if she were still startled by it. ''I was throwing sheets and screaming.'' For a full month afterward, she slept on the living room couch, unable to confront the bed again.
      It was pure desperation that led her to the support group, which she learned about through her occupational therapist at Fort Campbell's hospital. ''I didn't know what was wrong with my head,'' she recalled. But hearing other soldiers talk about what they were grappling with helped her understand that she needed -- and had access to -- help. ''After the first meeting, I almost cried with relief,'' she said. The sessions also gave her the courage to see a therapist, who prescribed Clonazepam for her anxiety and Lexapro, an antidepressant. On her third visit to the group, she managed to sputter out the story of the dead marine before breaking down in tears. When she tried to stuff the emotion back inside, it wouldn't go. ''I didn't want anyone to see me that weak, so I grabbed my keys and started to get up to leave,'' McKinley remembered. And then came the kind of touchy-feely moment so many of the soldiers claim they're not looking for: the guy sitting next to her, one of the wounded helicopter pilots, laid a friendly hand on her shoulder, coaxed her back into her seat and, without saying a word, let her know that it was O.K.
     Often during my visits with injured soldiers at Fort Campbell, I would ask what they envisioned as happening in the next few months when the rest of the 101st Airborne -- plus another 100,000 or so troops around the country -- began arriving home as part of the largest troop rotation since World War II. Would returning soldiers suffer the same nightmares and anxiety, the same alienation from both intimates and the world at large, that so many of the soldiers I encountered described having? In essence, I wondered whether the wounded, as the first large group to come back from Iraq, were like canaries in a coal mine, their postwar struggles foretelling those of thousands soon to come. Usually the answers ran along the same lines. ''There will be problems,'' Robert Shrode said. ''There'll be a lot of short fuses, a lot of intolerance. People are going to have to be patient with these guys.''
      The fact that post-traumatic stress disorder can develop from fear and anxiety raises particular implications in a war like the one in Iraq, where a seemingly straightforward army-versus-army scenario has long been dispensed with, replaced by the uncertainties of guerrilla warfare. Though military researchers have estimated that 25 percent of soldiers on the front lines of a war will experience combat stress, it seems possible that for Iraq the numbers will be even greater. ''These troops know no front line,'' says Alfonso Batres, the clinical psychologist in charge of readjustment counseling services for the 206 Vet Centers around the country. ''It's just like Vietnam. They have to be on guard with everyone; they're always facing an unknown. In some ways, fighting a conventional war is a lot easier on the psyche.''
      Even as the military works to provide mental-health care, history shows that the vast majority of soldiers returning from war will never seek help. Or they will do it years later, when the psychological afterburn has wreaked havoc on their lives. Steve Tice, a retired Vet Center counselor and disabled Vietnam veteran, refers to the legions of soldiers who live alone with destructive war memories as the ''invisible wounded.'' Says Tice, ''There's this unfortunate stigma we attach to soldiers who say, 'I hurt.' And so soldiers don't say anything.'' In this respect, it is conceivable that the physically wounded may have a slight advantage over their peers. Whereas most soldiers without major injuries will touch down on American soil and undergo a relatively impersonal and perfunctory post-deployment medical screening before returning to duty, many of the injured soldiers have already spent months being routinely examined, assessed and questioned about their well-being -- arguably making it easier to ask for help.
      One morning I stopped in on Jeremy Gilbert, the medic hurt in Kuwait, as he sat on a hospital bed, awaiting the fourth operation on his leg in six months. His cane lay hooked over the arm of a nearby chair. Two weeks earlier, just as he sensed he was making progress healing, an infection flared up and remained untamed by antibiotics. This was his 10th day as an inpatient, and he was accordingly listless. He had brought his Xbox and was playing video games to pass the time. ''My morale is kind of down,'' he confessed. Across the hallway from Gilbert's room on Ward 4A-B, the beds were full -- two to a room -- of soldiers freshly evacuated from Iraq. I had met a National Guardsman from Kansas who had been hit by an improvised explosive device in the Sunni Triangle, an Army sergeant from California who had had his leg fractured in a roadside ambush and a small-framed 21-year-old New Yorker who had collapsed during a long march and now had permanent nerve damage in both legs. For the most part, they seemed stunned, anxious to be cleared to go home on convalescent leave, and not quite ready to talk about what had happened. But Gilbert, who as one of the first casualties to be flown out of the gulf seemed to relish the role of elder statesman, used his own experience to predict what lay ahead. ''At first you're like, wow, I'm injured,'' he told me. ''The news on television is all about Iraq. You're like, this is good; I was part of something good. But then suddenly the news is bad -- it's all about soldiers dying -- and you're not healing the way you thought you would. You start thinking, I wish they'd cut my leg off. You think maybe I was supposed to die.''
      Gilbert refers frequently to his ''bitter period,'' which stretched through the summer and involved a lot of sitting around in a wheelchair, playing solitaire, watching ''M*A*S*H'' reruns and refusing to leave the house except for doctors' appointments. It ended, slowly, after his wife, Andrea, who was pregnant with their first child, begged him to ask his doctors for antidepressants. He says he resisted, knowing his request would become part of his medical records, potentially affecting security clearances and promotions in what he hoped would be a full military career. (This was a sticking point for a number of soldiers I spoke with: patient privacy laws apply only loosely in the military, where commanders have access to a soldier's medical history, including what goes on in counseling sessions.) For Andrea Williams-Gilbert, the kick in the pants she gave her husband represented a small bit of military-spouse activism. ''Wives and family members shouldn't have to go through some of what we have to because their spouses are afraid to go on antidepressants,'' she told me. ''It's not fair to anyone.''
      Even stabilized with Elavil, Gilbert said he has cycled through ups and downs, and Andrea, an outgoing blond Arkansan who was hugely pregnant when I first met her, does what she can to ride the waves. ''He'll say something touchy, and I'm out of there,'' she told me in November. ''I just head out the door and go walking.'' A week or so later, just before Thanksgiving, their daughter, Lauren, was born. Until he was hospitalized again, Gilbert had been more buoyant, regularly reporting for physical therapy, taking classes at a local university and doting, as best he could, on his wife and child. He was hoping to stay in the Army for a few more years after he recovered, but worried that if he ''toughed it out'' for a while, the fact that he was able to perform his duties (though in pain) would lower his disability rating when he did leave the service -- a difference of potentially thousands of dollars. And as it often does, fatherhood also rearranged his priorities. While earlier he was eager to get well so he could be redeployed to the Middle East, he announced to the support group in December that he'd changed his mind. ''I'm not going back there,'' he said, imagining a conversation with some higher-up in the Army. ''I'm not going to die for you.''
      Whether he had wised up or had grown pessimistic, it was hard to say. Knowing that the rest of the 101st Airborne Division was soon to return to Fort Campbell, Gilbert made another prediction from his hospital bed, saying he had a ''bad feeling'' about the homecoming. ''You've got a lot of units pulling security every single day, doing missions every single day,'' he said. ''They're seeing explosions, shootings, burning bodies. And they're going to bring that back to a place where there are lots of people who just won't get it. We're about to have 20,000 people walk through their front door for the first time in a year.'' He pursed his lips, shook his head as if still thinking about it and then laughed. ''If I were a divorce lawyer, I'd be in high cotton this winter.''
      Remembering how lonely she was as an inpatient at the base hospital, Jenni McKinley sometimes finishes her daily occupational-therapy appointment on the second floor and wanders up to Ward 4-AB to pop in on new arrivals from Iraq. It was there that she met Caleb Nall, a blue-eyed 23-year-old corporal from Louisiana who was recovering after being hit in the back by a rocket-propelled grenade. His torso had been severely burned; a gaping shrapnel wound had hollowed out part of his pelvis, and his left leg had been damaged. The explosion left him about 70 percent deaf in one ear. ''He was frustrated and tired of being in bed,'' McKinley said. She showed him her scars, invited him to come to the next support-group meeting and then the next day dropped off a few back issues of Maxim magazine and a case of Dr. Pepper. When it came time for the group's next meeting, Nall showed up. He wore a pile jacket and a pair of jeans, his wounds hidden well away but his anger fully exposed. After a visiting V.A. representative started to natter on about how soldiers needed medical evidence and a formal diagnosis of post-traumatic stress disorder to receive relevant disability payments, Nall jumped in. ''Would you say waking up with the sound of a mortar round going off next to your head counts?'' he asked, the bitterness thinly wrapped in his Louisiana drawl. ''Jumping six inches off your bed?''
      After the V.A. rep left, Nall turned to the group at large. ''Anyone else here having sleep problems?'' he asked. Brent Bricklin raised his hand. So did Jeremy Gilbert and Jenni McKinley and Robert Shrode, as well as four of the five other soldiers who had come that day. Everybody but Nall burst out laughing. ''Is there something else they did for you?'' he continued, perplexed. ''I'm on morphine, Percocet, Elavil. . . .'' ''I did Vicodin and Benadryl, but they counteract each other,'' offered a soldier across the room. ''Have you tried drinking?'' asked another. Nall nodded earnestly. ''I take two Percocets and drink two six packs of beer, and I still can't sleep.'' This set off a voluble round of pharmaceutical recipe-swapping. Injured soldiers, I have learned, are nothing if not experts on painkillers and sleep aids. And yet little seems truly to work. A few complain that their antidepressants cause them to sleep all the time; more -- like Nall -- report that they sit up half the night in a drugged daze, waiting for sleep to come.
      It was on one of these nights not long ago that a garbage truck arrived at 2:30 a.m. to empty the Dumpsters at Nall's off-base apartment. At the first slam of a Dumpster on pavement, Nall, who had been dozing in an easy chair dressed only in his underwear, was back in Iraq. ''My rifle was sitting in the corner,'' he said. ''I grabbed it, ran outside and made a loop around the block.'' Here, he paused to shake his head at just how scary this seemed in retrospect, and how utterly beyond his control. ''I was lucky it was the middle of the night, or I'd be in jail right now.'' The rifle is one of seven guns he keeps at his apartment.
      The potential for violence is just one of a list of concerns both the military and veterans' groups have for returning soldiers. Combat veterans have been linked to higher incidences of drug and alcohol abuse, domestic violence, depression and unemployment. Having learned from its failure to treat traumatized Vietnam War soldiers 30 years ago, the military has dispatched ''combat stress teams'' to Iraq to offer counseling and in some cases dispense antianxiety meds to suffering soldiers. It may be impossible, however, to fully counteract the shock of going from a 24-hour state of generalized fear-apprehension-paranoia, sustained for a year through wartime, to evenings at home on the La-Z-Boy, asked to fulfill the requirements of love and tenderness needed to sustain a family. In a well-publicized string of incidents in 2002, three Special Forces soldiers returned to Fort Bragg, N.C., from Afghanistan and killed their wives in a span of six weeks. All three soldiers committed suicide.
      It is unclear whether today's veterans will avoid the hardships that yesterday's continue to know. ''It won't be different for these guys than it was for the Vietnam vets,'' says Shad Meshad, the president of the National Veterans Foundation, who has counseled soldiers and veterans for the last three decades. He says that antidepressants and psychologists can only do so much for a hurting soul. ''There's a voice that rings through all these guys who've paid the price to survive war. No matter how much science or technology you have, those memories never leave you.'' Based out of Los Angeles, Meshad operates a hot line for war veterans. Until recently, the calls came from veterans of Vietnam and of Desert Storm, but in late fall the Iraq calls started to come -- not from soldiers but from their families. ''They're saying, 'Johnny came home, and he's angry; he wants a divorce,''' Meshad says. ''It's all the stuff I've heard from other wars.''
      What might save some of today's soldiers is their awareness of the struggles of past veterans and of the resources available to them now. Not only are soldiers better educated and slightly older than their forebears in Vietnam; they are more likely to be married and have children -- meaning more people will be directly affected by their ability or inability to recover from war. On the day I met Debra Shrode, Robert's wife, at the hospital at Fort Campbell, she sat quietly holding his hand. There was an uneasy tenderness between the two, and Debra, who is tall and pretty, with wide down-turned eyes, seemed at first reluctant to speak. ''I told you she was shy,'' Robert said, grinning. But she did speak. In a hill-country Kentucky drawl, Debra softly described getting the call last June from a commander, telling her that Robert had been hit by a grenade. She described the first time he was able to call her from the Army hospital in Landstuhl, Germany, about four days after the incident. (''He told me he was fine,'' she said. ''I lied through my teeth,'' Robert added.) And then she talked about his homecoming -- about meeting his medevac flight, ''scared to death,'' and first taking in the sight of his scar-ridden face, his weak body and missing arm. She remembered smiling as hard as she could at Robert before stepping out of his line of vision as the medics transferred him to a stretcher and letting herself weep.
      At home, the awkwardness rarely seemed to lift. When Robert's nightmares drove him to sleep on the couch, Debra lay awake in the bedroom. ''I kept wondering, Is he sleeping down there because he rests better, or is it because he doesn't want to be beside me?'' she said. And while six months after Robert's return their relationship had stabilized somewhat, Debra was still adjusting to what the war has done to her husband. Even as she kept busy going to cosmetology school by day and selling lottery tickets in the evenings, she couldn't help feeling ''left out,'' since Robert seemed to prefer the company of Bricklin and other soldiers to her own. ''I know there's a lot of things he can't talk to me about, that he can talk to his friends about,'' she said, glancing at Robert, who was by now staring quietly at the floor. ''But I'm sitting there thinking, Why can't he talk to me?'' She added that she has become better at living with the distance between them. ''At first, I had thoughts of holding his hand, of wanting to be close with him,'' she said, a quiet resignation in her voice. ''But stuff like that's changed, too.''
      For his part, Robert said that he couldn't get past the memories of Iraq, that his experience there felt unresolved. ''My body's here, but my mind is there,'' he said. Despite the injuries he had suffered, Shrode remained loyal to the war effort. ''We're doing good over there,'' he told me. ''People just don't see it.'' When it came to the future, he felt only confusion, saying, ''I'd like to live out West, but what kind of job could I do?'' He was interested in Wyoming, but remembered that cold weather makes his pain worse. ''One day I'm on the Internet searching for property there, and the next day I'm looking for a condo in Key West.'' He had thought about going to college to study forestry or real estate or to become a teacher, but his limitations always came rushing back. ''I type slow. I write slow. I can't carry heavy things. What am I going to do for work?''
      Anticipating the challenges of receiving compensation and care from the V.A., he had recently joined the Veterans of Foreign Wars. He was also going to sign up with Disabled American Veterans and the American Legion, and just in case, he was going to hire a lawyer. When I asked what his image of a group like the V.F.W. was, Robert said, ''A bunch of old guys from Vietnam sitting around in field jackets, drinking and not talking about it.'' Did he sometimes worry that he, too, might end up as one of those guys? Robert paused for a long, sobering moment. ''Yeah,'' he said finally. ''I do.''
     As Christmas approached, Caleb Nall's insomnia had not subsided. He announced to the group that his doctor had heard out all his complaints and then had the gall to suggest he add a warm bath to his routine. ''A warm bath -- c'mon!'' Nall said. Meanwhile, Jeremy Gilbert had consulted his doctor about all the pain medication he was taking. Earlier in the fall, he had started shortening the time between his prescribed doses of Percocet until suddenly he was taking twice what he should. Gilbert, who is studying to apply for a physician's assistant degree and can be aptly professorial, cautioned everyone about Percocet. ''They say it's as addictive as heroin,'' he said. Having recently replaced Percocet with controlled-release OxyContin, Gilbert admitted to having a ''serious physical dependence'' on it, developing a crushing headache every time he tried to skip a dose. ''It gets to where you'll kill somebody because you need that fix,'' he joked. ''I'm strung out on Demerol all the time,'' Jenni McKinley piped up. ''I know it's time to take my meds when I start screaming at my kids for little things.'' She added, ''My doctors are talking about switching me to methadone.'' Gilbert laughed. ''Mine said the same thing.''
      Whatever lay ahead for them couldn't be as bad, they figured, as what they went through the first few months following their return from war. Or at least they hoped as much. In an attempt to salve her conscience, McKinley had done some research on the marine who died next to her in Iraq, learning his name and the fact that he had left behind a young wife. She was contemplating calling his family, but eventually decided against it. Meanwhile, she had gained some strength and movement in her injured hand and was feeling better able to enjoy her children.
      Robert Shrode, meanwhile, has a new prosthetic -- a high-tech beauty complete with realistic-looking fingers --and was out on the air strip on Feb. 1 when the men and women of his unit returned home. At Fort Campbell, the troop rotation is now fully under way, with planes landing almost daily at the base, each one carrying up to 200 soldiers fresh out of Iraq. Shrode says that he has decided against having more of his arm amputated and is now embarking on the series of doctor's exams he needs in order to receive a medical discharge. His aim is to be out of the Army in April. He has also hit upon a new idea for his future: returning to Iraq as a security contractor for a private company. If it all works out, he could be back in the desert by next January -- his wife, he says, is against it.
      Meanwhile, Brent Bricklin's four-year enlistment is up in June. He plans on marrying his girlfriend in Wisconsin, with Shrode as a groomsman, and then he wants to go to college to become a history teacher. Imagining this, he expressed the first bit of military pride I had heard from him. ''I can't wait for the day I say: 'O.K. class, close your books. Today we're going to do Operation Iraqi Freedom. This here is my Purple Heart; here's the Iraqi flag I got off a rooftop in Karbala; these are pictures from Mosul.' How cool will that be?'' But while the dream of this moment kept him going, it also -- he finally admitted -- prevented him from seeking psychological help for the grief and anger he felt in the wake of his time in Iraq. ''I can't have any of that on my record,'' Bricklin told me, as if there were absolutely no choice in the matter. ''I mean, who's going to hire a teacher who has flashbacks?''
     At night, in the quiet of their rented farmhouse, Robert Shrode lets Debra pick the shrapnel out of his body. Over the last six months, she's tugged out 15 pieces as they have worked their way to the surface of his skin. She has picked them from his legs, from his neck, his face. Sometimes he will study them, these twisted aluminum chunks that have managed to escape while so many more will forever live inside him. Barely out of her teenage years, Debra Shrode never pictured her life this way. Never imagined the Army would be calling her up and asking her to hand out advice as some kind of expert wife. Yet someone from the Army's Family Readiness Group wanted her to call another wife whose husband had come home injured. She sighs and dials the number. ''I don't know what I can say to make you feel better,'' she says into the phone. ''If he doesn't want to talk, don't take it to heart.'' She adds each new piece of shrapnel to the collection they keep stored in a Tupperware container. For a while, the container sat on their coffee table, but recently Robert moved it into a spare bedroom drawer. If it seems as if he might be moving on, Debra has only to ask, What're you thinking about? ''Iraq,'' he'll say. And then the silence falls again.