Operator Syndrome: When the War Comes Home in Silence

by Chris Frueh, PhD

Editor’s Note: This 4-part series was adapted by Chris Frueh, PhD, from his book titled Operator Syndrome (2024; Ballast Books). The pattern of injuries and impairments associated with the Operator Syndrome framework is often seen in soldiers from the combat arms, private defense contractors, intelligence agents, law enforcement officers, and firefighters.

“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.”
—Clay Jensen, U.S. Army Master Sergeant (Ret.), Special Operations Team-Alpha (SOT-A), 7th Special Forces Group, Other Government Agency (CIA) contractor

“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

Imagine 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. His expression is flat, his face weary. His shoulders slump slightly, and he often stares at the floor.

During the clinical interview, he admits he has been drinking heavily for months and argues more with his girlfriend. He doesn’t understand what’s wrong—he’s never been like this before.

In most modern medical settings, this patient is almost guaranteed to receive a diagnosis of major depressive disorder, and likely one or two other psychiatric disorders. If he’s a service member or veteran, PTSD will often be added. Prescriptions will quickly follow. Within a short time, he may be taking at least two antidepressants (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 once by VA clinicians.

The doctor will probably refer him for psychotherapy, usually with a social worker or master’s-level mental health counselor. After waiting for months, the therapist he finally sees will be kind, supportive, and well-intentioned. The focus, however, will be almost exclusively psychological: “It’s all in your head.” The therapist may explore childhood and adult traumas, emotions, relationships, suicidal ideation, and firearm access.

But what if the root cause of these symptoms is a severe pathophysiological dysfunction—something that could be identified with a simple blood test? What if he has an endocrine disorder—specifically hypogonadism? Very low testosterone could explain every symptom he described, yet virtually no mental health professionals routinely check for hormonal dysregulation. This almost never happens.

Neither the VA nor the Department of Defense includes hormone panels in their standard operating procedures. That means patients are often treated for the wrong illness. While therapy may offer insights and psychiatric meds may help somewhat, treating physiological dysfunction with psychiatric drugs often causes more harm than good.

Imagine a baseball coach trying to help a hitter by focusing solely on childhood traumas and emotions, ignoring the physical mechanics of hitting. That coach would be ineffective—and so is an overly narrow mental health approach to complex physiological problems.

In over thirty years as a faculty member at large, multidisciplinary academic psychiatry departments, not one of them had an endocrinologist. The faculty included psychiatrists, psychologists, social workers, statisticians, sociologists, and geneticists—but no endocrinologists.

Mental health has drifted away from biology and medicine. Instead of interpreting “psychological” symptoms as signs of psychopathology, perhaps we should see many of them as second- or third-order effects of physiological dysfunction.

We need a whole systems approach—one that includes the nervous, endocrine, musculoskeletal, perceptual, pulmonary, digestive, and cardiac systems, as well as family, community, and occupational systems. In the SOF community, military units, transition services, Veteran Affairs, and support organizations are also essential systems to include.

In our 2020 medical journal article, we proposed a framework to understand the unique and complex injuries that arise over the course of a career in 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.¹

Mental health concerns are certainly relevant for operators, combatants, and first responders. But the overwhelming focus on psychiatric diagnoses—especially PTSD—has distracted us from chronic medical conditions that often go undetected and untreated.

It’s time to bring physiological injuries, chronic health conditions, and social challenges into the foreground. While my viewpoint may seem counterintuitive, I believe our current system fails to address many of the root causes of rising SOF suicides.

Allostatic Load – “Whole Systems” Approach

“Allostatic load” refers to the cumulative toll of chronic physical and psychological stressors. A career in SOF means chronic stress, trauma, and physical injury—including traumatic brain injuries. This accumulation leads to profound physiological changes. I believe it creates a profession-specific syndrome of interrelated medical, social, and psychological conditions.

Operator Syndrome: A Brief Overview

Operator Syndrome is a constellation of interrelated conditions common to military special operators. These include traumatic brain injury, endocrine and hormonal dysfunction (e.g., low testosterone), sleep disorders, chronic pain, headaches, depression, anxiety, anger, hypervigilance, PTSD, substance abuse, perceptual and cognitive impairments, marital and intimacy concerns, transition issues, existential struggles, and possible toxic exposures.

The Operator Syndrome framework can be used to understand both the long-term effects of a career in special operations and to optimize performance along the way. Each domain can be assessed individually by specialists, but the value of a syndrome-based approach is in seeing the bigger picture. That’s why we created the public-domain Operator Syndrome Scale, designed to help:

1. Learn about Operator Syndrome.
2. Understand your health, wellness, and functioning.
3. Facilitate conversations with your partner.
4. Guide conversations with your healthcare providers.
   

Implications for Performance Optimization

While Operator Syndrome helps explain long-term injuries, it’s also valuable during active duty. I regularly coach operators in their twenties and thirties on optimizing diet, sleep, recovery, and proactive health testing (e.g., hormone panels). We work on improving relationships, parenting, mindset, and future career plans. The framework is practical across all career stages—from selection to retirement.

“Special Operators are expected to perform optimally while deployed in the most austere environments with the bare minimum when it comes to health and wellness resources. We spend more time and attention maintaining our equipment than we ever do maintaining ourselves. Our healthcare needs to match our level of performance and consider the environments we operate in. Conventional medicine is not meeting the standard.”
—Geoff Dardia, functional medicine certified health coach, U.S. Army Special Forces Master Sergeant, founder of the SOF Health Initiative Program

There is Strong Hope for Recovery and Healing

We have powerful therapies that can restore health and quality of life. Traditional therapy and psychiatric medications play a role, but many newer treatments are showing promise—often unknown even to experienced clinicians.

Bilateral stellate ganglion block (SGB), ketamine infusion therapy, transcranial magnetic stimulation, and psychedelic plant medicines can provide lasting relief from depression, PTSD, anxiety, anger, and insomnia—and may improve cognition, relationships, and perspective.

SGB is known to treat certain headaches and neck/shoulder pain. Combined with ketamine, the benefits may amplify. Other life-changing treatments include hyperbaric oxygen therapy, speech and vestibular therapy, testosterone replacement, CPAP, peptide therapy, exome therapy, and stem cell treatments.

Some of these therapies may even promote neuroplasticity—the growth and strengthening of brain pathways. In short: physiological injuries—and psychic pain—can heal.

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References

Christopher Frueh, et al., “‘Operator Syndrome’: A unique constellation of medical and behavioral healthcare needs of military special operations forces,” The International Journal of Psychiatry in Medicine, 55, no. 4 (2020): 281–295.

About the Author

Christopher Frueh, Ph.D., is a novelist, clinical psychologist, and professor at the University of Hawaii. He has 30+ years of experience working with military and first responder communities, and has authored over 325 scientific publications. This series is adapted from his book, Operator Syndrome (2024; Ballast Books).

As the Voice of the Veteran Community, The Havok Journal seeks to publish a variety of perspectives on a number of sensitive subjects. Unless specifically noted otherwise, nothing we publish is an official point of view of The Havok Journal or any part of the U.S. government.