Stoked by an adversarial media and the run-up to Presidential elections next year, the trauma afflicting our body politic often seems more important than the deaths, physical disability and post-trauma stress disorder that afflict servicemen on the frontlines.
In this paper, I review the historical origins and verify the prevalence of what was whimsically called “soldier’s heart” in the Civil War and “disordered action of the heart” (DAH) or neurasthenia at the turn of the century and has now gained cognizance as “battlefield fatigue” or PSTD. The etiology is vast, since combat stress seems to provoke a great many physical, physiological and anxiety-related disorders. Lastly, I investigate the treatment options.
War is ever a violent business. If the North-South Civil War shocked Americans with unheard-of casualty counts and the violence of battles waged at the dawn of the industrial age, World War I traumatized the world with the unremitting violence brought to bear in hopes of breaking the stalemate that was the Western front. Poison gas, the machine gun, barbed wire, and massed artillery bombardment sent casualty counts sky high. Besides the United States, 17 other countries on both sides of the “war to end all wars” suffered no less than 5.7 million soldiers killed and another 12.8 million wounded.
Soldiers at the frontline were brutalized by the sheer violence of artillery bombardments, the random deaths these caused and the experience of seeing an unceasing number of their fellow soldiers slaughtered by gas or machine gun fire. It was then that the nervous condition first termed “war neurosis” or “neurasthenia” manifested in great numbers. Eventually, the equivalent term “shell shock” came into wider use.
Combat stress reactions first came to the attention of the medical establishment (psychiatry was in an embryonic stage then) in the second half of the 19th century and early in the 20th when physicians came to recognize adverse reactions that had more to do with sustained exposure to battle conditions than any physical injury. In retrospect, the Civil War condition then termed “soldier’s heart” was really a form of “combat stress reaction”.
During the Boer War waged by the British in South Africa (1899-1902), due notice had already been given to either “disordered action of the heart” (DAH) or neurasthenia/shellshock. Retrospective analysis of British soldiers who had been pensioned off for these conditions (Jones, Vermaas, Beech, Palmer, et al. 2003) found no especially significant difference in mortality compared to comrades who filed for disability owing to bullet or shrapnel wounds.
The Russia-Japanese War of 1904 and 1905 gave Russian physicians their first reported exposure to, and the opportunity to try and treat, nervous breakdowns owing to the stress of warfare, compounded by the demoralization of losing to the Japanese.
Later in the 20th century, the evolving nature of the battlefield and the enemy – World War II, the Vietnam War, the Iraq and Afghan occupations being the more prominent examples – created unexpected new sources of stress that complicated the combat fatigue syndrome and led to the broader “post-traumatic stress disorder” coming into wide use. So whereas “combat fatigue” referred to “a mental disorder caused by the stress of active warfare”, “PTSD” revolved on post-combat “fatigue, shock or neurosis”.
V. Statement of the Problem:
In this research paper, we review the available authoritative sources to assess:
- The continuing prevalence of PSTD in the varied conditions of modern warfare.
- Short- and long-term therapy employed to resolve the disorder.
- The extent to which familial and community support ameliorates PSTD and improves patient outlook.
For a world that has experienced unremitting conflict since World War II, whether orthodox warfare, low-intensity conflict or insurgency, chances are that anticipating and providing therapy for stress disorders will be a continuing concern.
VI. Literature Review
A. The Character of Modern Conflict
In the aftermath of the Great War many people believed that they had seen the most terrible war the world will ever see. History would prove them wrong. In the century that followed, war became even more traumatic and horrifying in its brutality. From the Russian civil war to the present conflict in Iraq, war took an ever-heavier toll on the human psyche. Technology improved the methods by which death might be delivered but it has done nothing to strengthen the minds of those who had to bear it.
The Russian civil war that succeeded until after World War I was a horror to behold. Thousands died in the fighting between the White Russians and Red Russians. Thousands more froze in the winter for lack of appropriate gear. Worse, many civilians were murdered by both sides on mere suspicion of being collaborators.
World War II was a litany of terrors. Whole societies were brainwashed into supporting the war from an ideological standpoint. Millions of Jews were gassed and burned in the holocaust simply being Jews. The SS, the KGB and the Kempetai would murder anyone at whim. Thousands of women were kidnapped and raped as “comfort women” by the Imperial Japanese Army.
More than the individual or large-scale slaughter of men, the true horror of WWII was the torture it inflicted on societies. Entire cities were razed to the ground in terror bombing. Cities became prison cells where starving denizens were forced to labor endlessly. Men went off to war leaving women to tend the factories and leaving no one to care for the children.
Then there was the Atomic Bomb. A scant few scores of thousands died. Both cities were leveled to the ground. The radioactive damaged would endure for years. Even those who tried to help the victims were themselves victimized by the radiation.
In Korea and Vietnam, millions were fielded in grueling civil wars. Korean fought against Korean backed by Communist and Imperialist masters. The same would be true for Vietnam but with the inclusion of terrible chemical weapons that defoliated forests and would cause harm for generations to come. In turn, the Viet Cong and Khmer Rouge executed savage campaigns against their own people.
The Arab-Israeli and Iraq-Iran wars would institutionalize child-soldiery. Israel had a scant 4 million citizens to oppose over 200 million Arabs. When attacked by the Arabs, Israel would be forced to deploy all its manpower, along with women, to help fight off the invaders. Chemical weapons were also used. The Israelites were left to defend their small nation against all their neighbors.
Iraq and Iran would field child soldiers in countless thousands. They would be given rifles then thrown into battle against hardened veterans in the hope of at least slowing down the enemy. Muslim killed each other over essentially religious disputes.
But perhaps the worst war of the 20th century would be the War on Terror. In the past the enemy was a specific country or group of countries. If they bomb our territory we can bomb theirs. But today, the enemy is not a nation. Today, servicemen in Iraq or Afghanistan do not know where or when the enemy will strike. All they know is that the enemy is out there lurking amongst a hostile population.
The war on terror also has another unsavory aspect. The ‘enemy’ resort to bombing civilian targets back home. Worse, the soldiers know that their victories will only make the enemy more desperate and make them retaliate more against innocent civilians.
As if the violence of outright warfare and low-intensity conflict were not enough, American and British forces of occupation as well as the soldiers of every nation that serve in U.N. peacekeeping forces confront at least equal prospects of PTSD. Whether in the Korean DMZ, the former Yugoslavia, Iraq, Afghanistan, Somalia, Lebanon, Ireland, or Timor, every soldier on such assignments faces a multitude of perils.
In many cases, peacekeeping forces are in a low-intensity-conflict situation but hampered by rules of engagement that deny them the right to shoot first and shrug it off as a mistake. The potential for battlefield fatigue climbs higher with alien cultures and religions, a seemingly ungrateful, resentful and even hostile native population, suicide attacks, well-armed guerillas, booby traps, mortar and improvised missile attacks. Such occupying forces are also apt to lose the public relations war for being unable to stop factions from slaughtering each other such as happened in Iraq, Afghanistan, Israel, Lebanon, East Timor and Rwanda. And perhaps the unkindest cut of all is when their own country’s media deliberately distort the casualty count from fratricidal or genocidal conflict as having been caused by the occupying or peacekeeping forces!
B. Incidence of “Shell Shock”, PTSD and Precipitating Events
When “shell shock” came to be widely recognized in World War I, the initial hypothesis was that it was induced by an inordinate number of fatal casualties. In fact, about 10% of all military forces then engaged succumbed on the battlefield, double the rate in World War II (less than 5%, in great part because the wide availability of sulfanilamide averted more deaths from battlefield infection). Later came the realization that it was total casualty count that really mattered. Historical research shows that around 56% of soldiers on the Western Front were either killed or wounded. When every other fellow in one’s platoon gets hit, fatally or not, it is no wonder that stress casualties were as numerous as battle casualties.
The term itself, “shell shock” reveals the ingrained belief that psychiatric casualties from the horrors of the battles of the Somme, Marne, Ypres, etc. had suffered concussion (physical trauma to the head or brain) from a close call with an exploding artillery shell. Nearly a decade elapsed before a British War Office Committee realized (Military History Companion, 2004) that battle exhaustion and other varieties of war neuroses accounted for a far greater proportion of cases than concussion did.
Great Britain having entered the fray early, the numbers of servicemen afflicted with “shell shock” and assorted neuroses were significant.
By 1939, some 120,000 British ex-servicemen had received final awards for primary psychiatric disability or were still drawing pensions – about 15% of all pensioned disabilities – and another 44,000 or so … were getting pensions for ‘soldier’s heart’ or Effort Syndrome. (Shephard, 2000)
In the post-World War II era, the Vietnam war can be counted the most traumatic for the U.S. military, not least because of the failure to achieve a clear-cut victory and the dissatisfaction of the American public with a war that dragged on so long. Since the fall of Saigon in 1975, estimates of the long-term incidence of “post-Vietnam syndrome” (now recognized as PTSD) among veterans varied from a high of 30% in 1989 and a slightly lower 21% in 1996 (Allis, 2005).
The most authoritative review in recent years, by researchers from Columbia University and other institutions, suggested that the lower end of the range was the more realistic figure: nearly 19 percent of Vietnam War veterans succumbed to PTSD as a direct result of military combat. In addition, “The more severe the exposure to war zone stresses, the greater the likelihood of developing post-traumatic stress disorder and having it persist for many years,” said Bruce P. Dohrenwend, an epidemiologist at Columbia University. (McKenna, 2006).
Fast forward to the current occupation of Iraq. The Defense Department reports, based on a sample survey of over 1,600 Army soldiers and Marines, that around one-third (30 percent) of those who had been in “intense combat” were diagnosed with such mental health problems as PTSD and depression. Incidence appeared higher among soldiers deployed to Iraq at least twice and for more than six months at a time (Bookman, 2007). So distressing is the occupation, according to an Army study, that one in six of close 1 million soldiers “surged” to Afghanistan and Iraq will very likely be afflicted with PTSD (Allis, op. cit.).
The reality turned out to be worse. Even more appalling estimates of incidence were reported by what has to be the most thorough accounting of the prevalence of post-traumatic stress disorder (PTSD) and conditions resembling chronic fatigue syndrome (CFS), a survey by Kang, Natelson, Mahan, Lee, & Murphy (2003) on the entire population of 15,000 Gulf War and 15,000 non-Gulf-War veterans. Information was gathered in 1995-97.
Gulf War veterans reported significantly higher incidence of PTSD (adjusted odds ratio = 3.1, 95% confidence interval: 2.7, 3.4) and CFS (adjusted odds ratio = 4.8, 95% confidence interval: 3.9, 5.9). Furthermore, “the prevalence of PTSD increased monotonically across six levels of deployment-related stress intensity (test for trend: p < 0.01).
Back home, the Department of Veterans Affairs reported on an investigation of principally Persian Gulf War veterans (79%) who had availed of the National Referral Program (NRP) and visited war-related illness and injury study centers meant for combat veterans with unexplained illnesses . Over the period from January 2002 to March 2004…
The more common diagnoses were chronic fatigue syndrome (n = 23, 43%), neurotic depression (n = 21, 40%), and post-traumatic stress disorder (n = 20, 38%). Self-reported exposures related to weaponry… environmental hazards, stress…A small increase in mean SF-36V mental component scores (2.8 points, p = 0.009) and use of rehabilitation therapies (1.6 additional visits, p = 0.018) followed the NRP referral (Lincoln, Helmer, Schneiderman, Li, et al. 2006).
The political furor over U.S. deployment in the Middle East has led to permutations, including what Baker (2001) refers to as “Gulf War Illness”. The more combat exposure they had had, the greater the likelihood that veterans manifest depression, PTSD, fibromyalgia, anxiety, and have generally poorer “health-related quality of life”.
For the British, a more sanguine view about involvement in Iraq may explain a finding that deployment to that strife-torn arena does not necessarily lead to increased risk of PTSD. Simon Wessely of the King’s Centre for Military Health Research at King’s College London reports that there is no evidence of anything like an “Iraq war syndrome” and that British troops returning from deployment were no more likely than U.K.-based soldiers to succumb to PTSD, anxiety or depression (New Scientist, 2006). Wessely seemed heartened by the fact that PTSD casualties this time around were significantly lower than during the earlier, even less controversial Persian Gulf War of 1991.
He also explained the advantage vis-à-vis incidence of around 20% for U.S. troops on three facts. First of all, British troops are more battle-hardened. “Two-thirds of British troops have been in deployments elsewhere, compared with only 10 per cent of US troops”. Secondly the US also uses more reservists (in the form of National Guard units) and has responsibility for the worst of the hostile combat zones. To an outside observer, the adversarial stance of the U.S. press and the inability of the American public to withstand sustained conflicts not amenable to victory over a visible enemy also count as contributing factors.
It would take an Englishman to look into the topic but tongue-in-cheek analysis by Ismail et al. (2000) of U.K. Gulf War veterans revealed that the chances of falling prey to PTSD are greater with lower rank (and, presumably, lower social status) and if one leaves the service.
Some research has shown that, far from being a steady state or amenable to permanent remission, PTSD has a way of recurring with the re-occurrence of the original precipitating factors or other less specific pressures, such as with serious illness or the sudden lifestyle change of retirement. In Israel, reactivation is a constant possibility owing to the fact the nation is always in a state of war with recalcitrant enemies so this potential trigger has come under scrutiny (Nachshoni & Singer, 2006). Case studies suggested that PTSD can recur even when the call to duty is for a family member.
In World War I, “shell shock” was observed principally as nervous fatigue. The famous photograph (see Figure 1, above) of a patient manifesting the “thousand-yard stare” became the enduring image of intolerable combat stress: glassy-eyed fatigue, slow reactions, indecisiveness, being detached from one’s immediate surroundings, and a certain vagueness about that needed doing first.
So great were the numbers afflicted and so vividly did the novel phenomenon manifest itself that even the popular press in the U.K. could accurately report the symptoms of battle trauma:
“Something was wrong. They put on civilian clothes again and looked to their mothers and wives very much like the young men who had gone to business in the peaceful days before August 1914. But they had not come back the same men. Something had altered in them.
They were subject to sudden moods, and queer tempers, fits of profound depression alternating with a restless desire for pleasure. Many were easily moved to passion where they lost control of themselves, many were bitter in their speech, violent in opinion, frightening. (Shephard, op. cit.)
The unfortunate circumstance of decades of unending small-scale conflict and insurgency campaigns post-World War II have enabled military psychiatrists to more fully define three key facets of combat neurosis and PTSD: fatigue, psychosomatic manifestations and neurotic symptoms.
Fatigue is the common denominator behind indecision and inability to concentrate, memory loss, constant waffling about priorities, little initiative, significantly slowed reaction time, seriously downgraded alertness and thought processes, taking refuge in obsessing and nitpicking unimportant details, and, most telling of all, difficulty with even routine tasks.
The element of neurosis crops up as fearfulness, anxiety, irritability, depression, confusion, paranoiac tendencies, fear of loss of control, and self-destructive behavior such as substance abuse or suicide.
Consequently, PTSD patients manifest the entire spectrum of somatically-induced disorders: headaches, backaches, (see also Mayor, 2000) being constantly high-strung, shaking and tremors, sweating, nausea and vomiting, loss of appetite, abdominal distress, frequency of urination, urinary incontinence, palpitations, hyperventilation, dizziness, muscle and joint pain (see also Ricks, 1997), insomnia and other sleep disorders. Barrett et al. (2002) found this psychosomatic explanation incomplete.
In a telephone survey of 3,682 Gulf War veterans and control subjects of the same era, the authors revealed that “Veterans screening positive for PTSD reported significantly more physical health symptoms and medical conditions than did veterans without PTSD. They were also more likely to rate their health status as fair or poor and to report lower levels of health-related quality of life.”
D. Long-term Effects
No doubt, psychosomatic disorders are of a piece with another syndrome physicians like to point to chronic multisymptom illness (CMI). Building on earlier studies that demonstrated CMI being more common among veterans who deployed to Saudi Arabia and Kuwait in contrast with those who had never participated in that campaign, Blanchard, Eisen, Alpern, Karlinsky, Toomey, Reda, Murphy, Jackson and Kang (2006) set out to assess the situation ten years after deployment and found that veterans were twice as likely to develop CMI:
Cross-sectional data collected from 1,061 deployed veterans and 1,128 nondeployed veterans examined between 1999 and 2001 were analyzed. CMI prevalence was 28.9% among deployed veterans and 15.8% among nondeployed veterans (odds ratio = 2.16, 95% confidence interval: 1.61, 2.90).
Blanchard et al. noted that those who did suffer from CMI had already been diagnosed for anxiety and depression unrelated to PTSD prior to 1991. Common CMI manifestations comprised frank medical symptoms, metabolic and psychiatric disorders. And those afflicted were more likely to smoke, besides reporting distinctly inferior quality of life.
M Hotopf, Anthony S David, Lisa Hull, Vasilis Nikalaou, et al. (2003) carried out one of the more comprehensive and authoritative studies of long-term effects, a two-stage cohort study on British soldiers who had deployed during the 1991 Persian Gulf War or on peacekeeping duties in Bosnia.
The study relied on four instruments: “self reported fatigue measured on the Chalder fatigue scale; psychological distress measured on the general health questionnaire, physical functioning and health perception on the SF-36; and a count of physical symptoms.” Military personnel who had been deployed elsewhere served as control group.
Table 1 — Prevalence of Categorical Outcomes (Values are percentages [.95 CL] unless otherwise indicated)
|Stage 1||Stage 2||Ratio* (new cases/recovered cases)||Stage 1||Stage 2||Ratio* (new cases/recovered cases)||Stage 1||Stage 2||Ratio* (new cases/recovered cases)|
|Fatigue cases||48.8 (45.4 to 52.2)||43.4 (39.9 to 46.8)||0.65 (0.45 to 0.85)||29.0 (25.6 to 32.4)||32.7 (28.6 to 36.8)||1.21 (0.83 to 1.59)||22.8 (20.0 to 25.6)||22.0 (18.6 to 25.4)||0.91 (0.56-1.26)|
|Post-traumatic stress reaction cases||12.4 (10.7 to 14.2)||10.8 (9.1 to 12.5)||0.73 (0.47 to 0.99)||5.7 (4.0 to 7.4)||6.0 (4.2 to 7.8)||1.07 (0.49 to 1.65)||4.0 (2.6 to 5.3)||6.6 (4.8 to 8.4)||2.45 (0.88-4.02)|
|General health questionnaire cases||40.0 (36.8 to 43.2)||37.1 (33.8 to 40.4)||0.79 (0.59 to 1.00)||29.2 (25.5 to 32.9)||31.5 (27.4 to 35.6)||1.25 (0.84 to 1.67)||25.3 (21.7 to 28.9)||23.8 (20.1 to 27.6)||0.88 (0.56-1.20)|
|Self reported Gulf war syndrome||18.6 (16.2 to 21.1)||15.8 (13.3 to 18.2)||0.58 (0.25 to 0.90)|
|All prevalence estimates are weighted for sampling.|
|* Values of <1 indicate declining prevalence. Ratios are weighted for sampling.|
Gulf veterans evinced a higher prevalence of fatigue, post-traumatic stress reaction, self-reported Gulf War syndrome and general health compared to the other two cohorts. The difference is consistent throughout stages 1 and 2. However, the veterans in question did show some improvement on all four measures over time.
Table 2 – Scores (.95 CL) for Continuous Measures, by Cohort and Stage
|Stage 1||Stage 2||Difference||Stage 1||Stage 2||Difference||Stage 1||Stage 2||Difference|
|SF-36* physical function||90.3 (88.3 to 91.3)||88.7 (87.6 to 89.9)||-1.6 (-2.5 to -0.7)||95.4 (94.4 to 96.4)||92.9 (91.6 to 94.1)||-2.6 (-3.8 to -1.3)||92.1 (90.6 to 93.6)||90.8 (89.2 to 92.3)||-1.3 (-2.7 to 0.1)|
|SF-36* health perception||65.8 (64.1 to 67.5)||65.9 (64.2 to 67.6)||0.1 (-1.2 to 1.4)||76.2 (74.4 to 77.9)||72.9 (71.0 to 74.8)||-3.3 (-5.1 to -1.6)||76.8 (75.0 to 78.6)||74.4 (72.4 to 76.4)||-2.4 (-4.2 to -0.6)|
|General health questionnaire||14.5 (14.1 to 14.9)||14.2 (13.8 to 14.5)||-0.3 (0.1, -0.6)||13.1 (12.7 to 13.6)||13.2 (12.7 to 13.7)||0.1 (-0.4 to 0.6)||12.4 (12.0 to 12.8)||12.9 (12.5 to 13.3)||0.5 (0.05 to 1.0)|
|Fatigue||17.8 (17.4 to 18.1)||16.9 (16.5 to 17.2)||-0.9 (-1.2 to -0.6)||15.6 (15.2 to 16.0)||15.3 (14.9 to 15.7)||-0.3 (-0.7 to 0.2)||14.7 (14.3 to 15.0)||14.9 (14.5 to 15.3)||0.2 (-0.2 to 0.6)|
|Total symptoms||11.0 (10.4 to 11.6)||10.7 (10.1 to 11.3)||-0.3 (-0.8 to 0.1)||6.2 (5.6 to 6.8)||7.9 (7.3 to 8.5)||1.7 (1.2 to 2.3)||5.3 (4.8 to 5.8)||6.4 (5.8 to 7.0)||1.1 (0.6 to 1.6)|
|All scores are weighted for sampling.|
|For SF-36 scores, negative differences in mean indicate a worsening in health. For other scales, negative scores indicate an improvement in health.|
|* SF-36 scales range from 0-100, with higher scores indicating better health.|
Table 3- Incidence and Persistence of Outcomes. (Values presented with 0.95 CL’s)
|Cohort||Risk||Crude odds ratio||Corrected odds ratio*||Risk||Crude odds ratio||Corrected odds ratio*|
|General health questionnaire cases:|
|Gulf||20.2 (16.4 to 24.0)||1.0||1.0||61.8 (57.3 to 66.3)||1.0||1.0|
|Bosnia||21.2 (16.7 to 25.8)||1.1 (0.7 to 1.5)||0.9 (0.6 to 1.4)||58.9 (51.9 to 65.8)||0.9 (0.6 to 1.1)||1.1 (0.7 to 1.6)|
|Era||15.4 (11.4 to 19.4)||0.7 (0.5 to 1.1)||0.7 (0.5 to 1.1)||48.4 (41.0 to 55.9)||0.8 (0.6 to 1.1)||0.6 (0.4 to 0.8)|
|Gulf||18.8 (14.4 to 23.1)||1.0||1.0||69.7 (66.4 to 73.0)||1.0||1.0|
|Bosnia||19.8 (15.1 to 24.4)||1.1 (0.7 to 1.6)||0.9 (0.6 to 1.5)||59.9 (54.2 to 65.6)||0.6 (0.5 to 0.9)||0.7 (0.5 to 1.0)|
|Era||11.2 (7.5 to 15.0)||0.6 (0.3 to 0.9)||0.5 (0.3 to 0.9)||58.2 (53.1 to 63.4)||0.6 (0.5 to 0.8)||0.7 (0.5 to 0.9)|
|Post-traumatic stress reaction cases:|
|Gulf||5.0 (3.6 to 6.4)||1.0||1.0||51.8 (44.8 to 58.9)||1.0||1.0|
|Bosnia||4.0 (2.5 to 5.5)||0.8 (0.5 to 1.3)||0.8 (0.4 to 1.5)||38.9 (24.3 to 53.3)||0.6 (0.3 to 1.2)||0.8 (0.4 to 1.8)|
|Era||4.6 (3.0 to 6.2)||0.9 (0.6 to 1.5)||0.9 (0.5 to 1.5)||54.8 (37.8 to 71.9)||1.1 (0.5 to 2.4)||1.2 (0.6 to 2.7)|
|* Controlled for demographic variables (age, sex, rank, marital status).|
Comparing scores for continuous measures, one sees that Gulf War veterans were less healthy at both stages of the longitudinal study, though they were stable as far as health perceptions were concerned and reported a statistically-significant, if slight, reduction in fatigue. One concedes that physical functioning declined for all three cohorts.
Additionally, Gulf veterans were more likely to experience persistent fatigue compared with the Era and Bosnia cohorts, a finding that remained significant after controlling for potential confounders (P = 0.009).
Overall, despite being less likely to manifest less fatigue (48.8% at stage 1, 43.4% at stage 2) and a lower prevalence of psychological distress (40.0% stage 1, 37.1% stage 2) over time, veterans of the Gulf War reported a decline in physical function on the SF-36 (90.3 stage 1, 88.7 stage 2). By all measures used, this group also attested to worse health indicators: a higher incidence of illness and more persistent symptoms.
Twelve years after helping smash the Iraqi incursion into Kuwait, the authors concluded, “Gulf war veterans continue to experience symptoms that are considerably worse than would be expected in an equivalent cohort of military personnel. However, Gulf war veterans are not deteriorating and do not have a higher incidence of new illnesses” (Hotopf et al., op. cit.)
E. Treatment Recommendations and Best Practice
1. World War I
Since little is known about the methods Russians used to treat their shock casualties during the Russo-Japanese War, the noted English psychologist Charles Myers – first University Lecturer in Cambridge (for the course Experimental Psychology) and appointed Consulting Psychologist to the Army in 1916 – is generally credited with the first systematic effort to treat PTSD (Bartlett, 1937).
While espousing the benefits of a congenial environment, psychotherapeutic regimens and even hypnosis, Myers was very emphatic about the value of providing succor as promptly as possible. Key to his proposals, therefore, was the establishment of special centers and rest homes close to the frontlines.
By Christmas 1916, two developments led to modifications of Myers’ preferred regimen. First, the British Adjutant General resisted physicians’ opinions that a soldier was a shock casualty and insisted on obtaining a certification from the victim’s commanding officer to the effect that the trauma was due to physical causes. This attitude was shared by the eminent British neurologist Sir Gordon Morgan Holmes, CMG CBE FRS, who was put in charge of the very active northern part of the front in December. Physicians reacted to the delays in committing victims to neurological centers by sending the men back to their units and urging their superiors to both monitor and engage with them.
By 1917, therefore, treatment for “not yet diagnosed nervous” (NYDN) had evolved to embrace the so-called “PIE principles”:
- Proximity – treatment close to the front and within earshot of the fighting to convince the soldier there was nothing wrong with him;
- Immediacy – treat without delay and give equal priority with wounded casualties; and,
- Expectancy – assure all victims of their return to the front after due rest and recovery.
Reviewing the CSR toll after the war, the British War Office saw fit to recommend treatment programs that included:
- Physical therapy – baths, application of mild electric current (recall that medicine has advanced greatly in the eight decades since then), massage rest and general recuperation;
- Psychotherapy emphasizing “explanation, persuasion and suggestion”; and,
- Crafts and hobbies;
- Hypnotherapy in selected cases for inducing deep sleep and evoking repressed memories.
As a rule, the British view of the time was weighted toward returning the afflicted soldier to useful employment in civilian life. For the military establishment was gravely concerned about the battlefield dangers of patients who manifested severe anxiety neuroses, other neuroses that required confinement in a mental institution or expert treatment back in the U.K itself.
Exhaustive research on combat stress reactions in the intervening years failed to prove conclusively that PIE-based programs were effective in forestalling PTSD (U.S. Dept of Veterans Affairs, n.d.). Hence, American Armed Forces are now more likely to be administered some variation of the BICEPS model:
- Centrality or Contact
2. World War II
The catastrophic experiences of World War I did not seem to adequately inform or pervasively improve Allied preparations as war clouds loomed in Europe. A generation had passed and British army doctors had generally served in France in the earlier conflict. Still, Shephard notes (op. cit.), they initially floundered about and it was not until 1942 that the first psychiatric hospital was even set up (for the then-beleaguered Middle East Force). When the time came to invade Normandy in June 1944, British army physicians quickly forsook the expectancy principle and routinely returned battle trauma patients home over the Channel.
For their part, the Americans initially imposed rigid screening pressures for mental ability in the rush of patriotic fervor that followed Pearl Harbor. Soon enough, this was abandoned for having no validity. Too many who tested well succumbed to “battlefield exhaustion”. In late 1943, the U.S. military approved a plan to add a psychiatrist to the T.O. & E. of every Army division shipping overseas but it was not implemented until March 1944, when the drive up the Italian “boot” was well underway.
This late in the war, nonetheless, the Allies made an important discovery: camaraderie and unit cohesion were effective shields against “exhaustion”. This finding naturally enough placed a premium on strong, effective leadership.
The Germans were more unequivocal in placing great reliance on the quality of the officer corps. In their view, the “war neuroses” that sapped the will of their fighting men was tantamount to cowardice and deserved to be treated as such. Beginning in 1942, however, when the Allies started the counterattack and the Afrika Korps was stymied, hospitalizations owing to battlefield trauma became too numerous to ignore (Belenky, 1987).
3. New approaches in the Post-War Period
Among other developments, the Israelis simplified PIE procedures by heightening the degree of support administered but keeping therapeutic confinement short. That this works at all is testimony to a nation of citizen-soldiers who must keep the economy working while perpetually staying on a war footing.
F. Treatment Success Rates
There is some evidence that proximal treatment is successful Despite the dual stress of fighting another occupying force, the Syrian Army, and Palestinian “refugees”, nine in ten CSR were reported fit to return to their units within three days but only 40% for those evacuated to a hospital ship cruising the eastern Mediterranean or back home (Gabriel, 1986). In turn, the U.S. Army claims in its manual “Combat Stress Control in a Theater of Operations” a similar success rate for proximate treatment (85%) in the Korean War (U.S. Army, Combat Stress Control in a Theater of Operations, n.d.). However, neither source tracked the long-term mental health of these soldiers, precisely the context in which one would expect PTSD to manifest.
A ray of hope is, however, cast by an authoritative Columbia University study (McKenna, op. cit.) suggesting that the majority of Vietnam war veterans spontaneously recovered from PTSD over time, frequently without having recourse to treatment from mental health professionals.
This review of the literature affirms that the advent of combat stress went hand-in-hand with the advent of industrial-era weaponry (in the Civil War) and mechanized warfare in succeeding conflicts. PTSD has many manifestations, can recur without warning and is certainly debilitating.
Even with the advent of psychotherapy, occupational therapy and tranquilizers, treatment centers still purvey variations on the BICEPS and PIE theoretical models, the latter developed by British physicians during World War I. There remains a great deal of uncertainty about the proximity component of the PIE model – returning the soldier to combat – after suffering CSR. It seems battlefront physicians take “successful cure” to mean being able to return warm bodies to the frontlines. Critics assert that re-exposure to combat is likely to aggravate matters in the future and perhaps even precipitate PTSD altogether. Though the longest available cohort study spanned just 10 years, there is no question now that PSTD has long-term effects.
Future researchers need to investigate more thoroughly the psychosocial, military, and environmental risk factors that stimulate onset or, on the other hand, recovery. One factor that bears investigation in-depth is the impact of victory or setbacks in a campaign.
To the extent that high morale and good leadership have been shown to have a moderating or even protective effect, one wonders what are the effects of fighting for survival (e.g. Israel), of community and country united behind a war effort (the Korean War, the Malayan emergency), of service in prior conflicts (the British SAS), of guilt and angst over being the globe’s last remaining policeman, and of coping with feudal cultures whose people are just as willing to apply savage tactics against U.S. servicemen as against each other. At the very least, further research might seek to determine the impact of attainable victory in sharp contrast with the ennui and self-destructive impatience over protracted conflict that mark American discourse today.
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