Memories from war haunt Adam Pepper's sleep. Bombs explode and gunfire rattles through dreams that replay the indelible image of his five friends killed before his eyes.
The nightly flashbacks of Iraq combat wake him hourly.
"They were shredded," Pepper says of the devastating ambush he can't get out of his mind. "It's just a blood bath."
Spc. Adam Pepper, 27, is in counseling for post-traumatic stress disorder. And he is not alone.
Pepper is part of a generation of young soldiers affected by the trauma of combat. More than 3,030 U.S. soldiers have been killed since the invasion of Iraq in 2003. Another 46,000 have been injured, and an un-recorded number of soldiers will suffer from post-traumatic stress disorder.
At least 30 percent of people who have spent time in war zones experience post-trauma symptoms, according to the Department of Veteran Affairs National Center for post-traumatic stress disorder.
"(War) was crazy. Just crazy," Pepper said. "The next second could be your last."
Pepper has been back from Iraq for two months. Under close-cropped brown hair, his calm face belies an inner turmoil left over from a year-long stint on dangerous Hummer patrols.
Pepper's mother and stepfather have lived in Truckee since 1992, and though he graduated high school in the Bay area, Truckee and North Tahoe are a huge part of his life.
At 25 years old, at the onset of the war in Iraq, Pepper enlisted.
"I wanted to do my part," he says.
Arriving in Fort Hood, Texas, in May 2005, Pepper learned the following month that he would be deployed to Iraq. He said he never expected to be on the frontline, but his good marksmanship landed him a spot as the lead bodyguard for his commander.
Trauma in real life
In Iraq, carnage is the way of life. Pepper was shot at multiple times. He was mortared daily. Shredded animal carcasses scattered the open desert he patrolled.
And five soldiers in his convoy were killed just vehicles ahead of him.
The first few seconds following the explosion that ended the lives of his buddies, Pepper said he didn't even realize what he was looking at.
"People get emotional. These are your friends."
In Iraq, Pepper was always on the defense, and even now he says it's difficult to leave the feeling behind. At the mall, driving to town or sleeping at night, Pepper is hyper-vigilant.
And while he does not describe his feeling as fear, he can't kick the anxiety of fending for his life.
PTSD - what is it?
Post-traumatic stress disorder, commonly referred to as PTSD, is a psychiatric disorder that can occur following life-threatening events such as military combat, natural disasters, serious accidents or violent assault.
While most survivors of trauma experience some symptoms, others develop stress reactions that do not go away.
When Pepper was in Iraq, he was so exhausted from working eight- to 20-hour days he slept like a rock. Now safely back at home, he startles awake every hour, sweating from combat-related nightmares.
"My brain is still running so fast," Pepper says.
Soldiers have support on hand, including counselors and chaplains. And talking with fellow veterans about similar experiences helps the most, says Russ Mann, a Vietnam veteran.
Mann, a Truckee resident and trauma nurse at Tahoe Forest Hospital also spent time in Iraq. While he did not have many post-trauma symptoms upon returning from the Vietnam War, he says soldiers who remain in the military have fewer incidences of PTSD because they have a built-in support group of people with similar experiences.
"Having a few beers and talking with your buddies is cathartic," Mann said.
Pepper finds solace in the counseling services the Army offered him.
"When I first got back, I was freaking out a lot," Pepper says. "If you never talk about it, you bottle it up and don't know what to do with it."
"Making your way in the world while suffering from PTSD is exhausting ... a constant state of high-alert," says Danielle B. Klotzkin, a marriage and family therapist in Truckee who has treated post-trauma in a variety of patients.
Efraim Estrada is a psychotherapist with Sierra Family Services in Tahoe City who worked for the Department of Veteran Affairs during and after the Vietnam War and treated post-trauma. He is currently treating one client in North Tahoe.
"There's a general de-compensation, a tendency to begin to experience difficulties in relationships ... potential for isolating self from family .... a tendency to want to avoid closeness and intimacy," Estrada says.
Many of Estrada's patients end up in counseling following a court referral, he says. The individuals are often dealing with relationship problems, substance abuse or other behavioral issues, which turn out to be an indication of combat-related PTSD, he says.
Post-trauma centers often treat soldiers with different forms of psychotherapy and drugs.
But the most effective treatment is group therapy, Estrada says.
Even though Pepper reports little difficulty with his relationships, he meets with a therapist to help resolve his issues with sleep disruption and extreme hyper-vigilance.
"Talk therapy integrates material ... into every-day life skills," says Klotzkin.
While Pepper is not scheduled to return to Iraq, he will serve in Korea for 18 months before finishing his enlistment.
Nonetheless, images of death and destruction are seared into his memory forever.
He'll spend months talking himself out of unnecessary panic, working toward a full night's sleep, and remembering his friends' lives before they were ended so violently.
But Pepper says he doesn't regret his decision to serve his country despite his own internal battles. And he knows thousands more young soldiers, with scars visible and invisible, are in the depths of combat right now.
What is it? Post-traumatic stress disorder is an anxiety disorder resulting from exposure to a life-threatening circumstance. While most survivors of trauma experience some symptoms, others develop stress reactions that do not go away. PTSD is characterized by re-experiencing the event, avoidance and hyper-arousal.
Symptoms: Detachment, sleep difficulties, flashbacks and nightmares, and hyper-vigilance, according to the diagnostic manual for mental disorders. These symptoms can significantly impair an individual's daily functioning.
Treatment of PTSD: PTSD is treated by a variety of forms of psychotherapy and drug therapy. While there is no definitive treatment, cognitive-behavioral, group and exposure therapy are the most common.
Cognitive-behavioral therapy works to change emotions, thoughts and behaviors. Group therapy is useful because trauma survivors share their experiences with other survivors. And exposure therapy involves having the patient relive the frightening experience under controlled conditions to help work through the trauma.
Medications such as Prozac and Zoloft are the most widely used drug treatments that help ease associated symptoms of depression and anxiety and to help with sleep, according to the Veteran Affairs Center for PTSD.
By the numbers
• An estimated 8 percent of Americans will experience PTSD at some point
• Women are twice as likely as men to develop PTSD
• 50 percent of women and 60 percent of men report experiencing at least one traumatic event in their lifetime
• 30 percent of people who have spent time in war zones experience PTSD