COL Tate, Chief of Chaplains at a military installation, was referred to Mental Health for a Command Evaluation. No one wants to be commanded by a higher authority to see a psychiatrist. It could be a cause for alarm, a career-stopper, oreven a medical discharge.
Initially, Col. Tate was guarded, taciturn, and ambivalent about cooperating with the evaluation. Every patient evaluates the doctor as thoroughly as the doctor is evaluating the patient. “I respect chaplains and see them as vital to military missions, COL Tate. Thank you for your invaluable service.”
COL Tate nodded his head affirmatively.
“In fact,” I said, “a chaplain saved my Rapid Deployment Combat Stress Control (RDCSC) Company. They redeployed from combat in the Middle East without their commander or their Property Book.”
COL Tate smiled. “Now they are in big trouble,” he said. “Every piece of equipment is recorded in the Property Book. I’ve seen Property Books with hundreds of thousands of dollars of equipment, all charged to the unit commander. You lose the Property Book, and you may as well go bankrupt.”
“I was ordered,” I said, “to take command of the company and return esprit de corps. Their former commander was in litigation over the amount he was required to repay.
“Psychiatrists, psychologists, social workers, nurses, and medical technicians comprised the company. They were a disgruntled crew when I first met them.
“The chaplain opened our staff meetings with prayer, and the company stood in formation for prayer by the chaplain after each drill. It took a while, but the winning combination of the good chaplain and daily unit running saved the RDCSC company. Most of the credit goes to the chaplain.”
The small examining room took on a softer, more pleasant glow.
“COL Tate, what’s behind this command referral?”
“The patient looked physically unwell, lethargic, and aloof. “I don’t know. It could be nothing, or it could be…I don’t like to say the word “dementia.”
“What makes you say dementia?”
“I’m 55 years old, and my memory is not as good as it was. I can go into a room for something and forget why I came into the room. Recently, I lost my train of thought. Sometimes, I just feel my mind is befuddled…not as sharp as I need it to be.”
“How long, COL Tate, have you been feeling this way?”
“It started sometime around 9/11.”
“How did your commander get involved? As you know, he ordered the evaluation.”
“That’s the puzzling part. I’m only guessing, but I, young chaplains under my command, do not accept the understanding of the Bible. They openly criticize me for stressing the sinfulness of sin. Their emphasis is on the social gospel, calling me a theological fossil. They want to replace me.”
“How well do you sleep?”
“I haven’t slept well for years.”
“The most common cause of your symptoms is the lack of sleep, not dementia. Why can’t you sleep?”
“I was in the Pentagon on 9/11/2000 when the terrorists crashed the airliner into the building. I was not seriously injured, but I saw terrible things. When I try to fall asleep, I have “visitations” of those terrible images. When I do fall asleep, I’m frequently awakened by nightmares.
“A chaplain should not be bothered by terrorists and the strife they inflict. I’m too ashamed of myself to share this with others. Today is the first time I revealed it.”
“Where is it written that a chaplain must be a superhuman?” He did not reply.
“What do you know about dementia, COL Tate?”
“I know little about dementia. It’s related to the brain, but what I know is scary.”
“The brain weighs 3 pounds, is covered with three protective layers of tissues, bathed in a sterile fluid, and contains neurons, stem cells, and other supportive cells. It is encased in the skull, which is composed of one of the strongest bones in the body.
“The brain cells communicate with each other through synaptic connections or gaps that receive and send vital information via chemicals called neurotransmitters.
“When Agatha Christie’s Hercule Poirot referred to the “little gray cells,” he meant neurons or brain cells.
“The number of cells and their synaptic connections in one 3-pound human brain is approximately the same as the number of stars in our galaxy; at least 100 billion! Intelligent design? Subject of a sermon?
“The Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5 Text Revision) defines dementia as a major neurocognitive disorder (NCD) that involves a substantial decline in cognition. This decline must be significant enough to interfere with daily activities.”
Criteria for major NCD
- Evidence of a decline in one or more cognitive domains
- The decline must be from a previous higher level of function
- The decline must be sufficient to interfere with independence
- The decline must not be primarily due to another mental disorder
- The decline must not occur exclusively in the context of delirium
Cognitive domains include:
- Attention
- Executive function
- Learning and memory
- Language
- Perceptual-motor function
- Social cognition
Other NCD
The DSM-5 also defines a mild NCD, which corresponds to mild cognitive impairment (MCI). In this case, the impairment is modest, but the individual is still independent in daily activities.
Dementia is a chronic condition that worsens over time. There is no known cure, but medications and therapies can help manage symptoms.”
“COL Tate, the first diagnosis on my list of differential diagnoses for you is PTSD. Of course, there are screening tests we can use to rule out dementia.
“We need to be kind and caring about our brain. We can be good to our brain by eating a balanced diet with ample fruit and vegetables (not capsules), maintaining normal body weight, and getting regular amounts of moderate exercise such as walking at least 150 minutes per week or 25-30 minutes daily (better). Restorative sleep is critical, and the brain needs at least 7 hours of good sleep. Mental stimulation, social engagement, stress management, and regular medical check-ups show you respect your brain.
“Dementia is caused by damage to brain cells (neurons). Scientists have identified several causative factors: neurodegeneration, vascular issues, infections, traumatic brain injury, other medical conditions, genetic factors, and lifestyle factors.
“The first MD degree in the American Colonies was awarded in 1770 by Columbia University, then known as King’s College. Medical students were taught then, and now there are no new neurons or brain cells after birth. You can lose brain cells, but you cannot make new ones, a concept refuted at the Salk Institute.
“Fred Gage, Salk Institute, proved that regular moderate physical exercise releases a hormone in the brain named Brain Derived Neurotropic Factor (BDNF). BDNF converts stem cells in the brain into neurons that migrate to the Hippocampus, where emotional memory is stored.
“The best minds in the world are studying optimal brain functioning. At this time, the most accurate description of dementia is brain malfunction that is likely caused by the interaction of environmental, genetic, and lifestyle factors.”
Chaplain Tate’s most recent military ratings were all in the superior range. Neuropsychological testing showed mild cognitive changes likely explained by chronic sleep disturbance. Reassurance and treatment of his PTSD soon returned him to his pre-morbid sense of well-being.
A new understanding of the complex human brain will ultimately identify the causes, cures, and prevention of dementia.
“Most of us can improve our lifestyle. For example, I have never treated a physically fit depression patient.
“Consider the potential risk of dementia associated with factors over which you have complete control: smoking, vaping, drug use, alcohol consumption, grudge-holding, hatred, fits of rage, or spiritual neglect.
“Make a list of your flaws and calmly, sensibly, and prayerfully confront them, pleading for the help of Almighty God and your best friend. Begin today to treat all others with kindness, dignity, and respect, starting with the first person you see in the mirror.
“Do you want the truth?”
Robert S. Brown, MD, PHD a retired Psychiatrist, Col (Ret) U.S. Army Medical Corps devoted the last decade of his career to treating soldiers at Fort Lee redeploying from combat. He was a Clinical Professor of Psychiatry and Professor of Education at UVA. His renowned Mental Health course taught the value of exercise for a sound mind.