They know what it's like to blow someone's head off or to see it being blown off, so when they get angry, that crosses their mind." But he said that couples and families often talk more about "the numbing" and "the inability to connect."
Armstrong also pointed out that many vets worry about the effect on their career of getting help, and how it looks to others if they do. "That's due to both their training and age group," he said, noting that 50 percent of soldiers are 17-to-24-year-olds, and 89 percent are male.
"So it's not just about war, but about the developmental stage of the troops," he said. "It's an appropriate age to be independent and not get any help. But that, combined with the stigma of asking for help and if they have PTSD avoidance symptoms can keep them from going in."
As a result of recent studies showing that PTSD can develop up to five years after discharge, the V.A. extended what was previously a two-year limit in which veterans could get help to a five-year window. They also now have a suicide prevention hotline number for vets: 1-800-273-8255.
"The V.A. overall has made some mistakes, but it has really taken suicide prevention seriously," Armstrong said.
There are nonprofit options as well. Founded in 1974, Swords to Plowshares provides counseling and case management, employment, training, housing, and legal assistance to homeless and low-income veterans.
Equally important, it's staffed by veterans like Walter Williams, who served in Iraq and Afghanistan and has combat-related PTSD, and Tia Christopher, a survivor of military sexual trauma. "The experience of being in a war zone as well, or being sexually assaulted by some one in your own unit, that's profound," Armstrong said.
As Christopher explained, she and Williams have similar symptoms and attend weekly V.A. appointments to deal with their own mental health issues, between providing services to other veterans at the group's Howard Street office.
"Pretty much everyone coming back has combat stress and everyone I know has been buying rifles," Christopher said, noting that cleaning guns can be a meditative therapeutic activity for veterans. "Combat stress becomes clinical PTSD when those symptoms don't go away."
Christopher said women who were in combat and survived military sexual trauma face "a double whammy." Out of the military for more than seven years, Christopher observed that "things get better, but the memories don't go away."
In 2007 there were more than 2,000 reported military sexual assaults, but only 181 were court-martialed, she said. "So basically survivors are dealing with injustice of nothing happening.
"I used to wish that PTSD gave you purple spots," she added. "That way people would know you had it. Instead, you are left dealing with getting panic attacks all of a sudden and being on edge."
"I call it a flare-up," Williams said. "It's different each time. Sometimes, when I have to focus and get my mind around something, I'm blank. I feel like I want to cry, but I can't."
Unlike past generations who openly identified as vets, "this new wave of vets is "more intent on blending in," Williams said. "They're trying to suppress their symptoms. They don't want to be seen as weirdos."
Deployed to Iraq and then Afghanistan as a communications specialist in 2004, Williams recalled having to give up his weapon twice and being put on suicide watch.