Warfare and Mental Health

The question is not whether PTSD is real and serious. It's a devastating mental illness. The question is how many veterans have PTSD, and clearly our goal should be to try to address the veterans' needs and help them deal with their problems and move on in life.

Chet Edwards

War is an institutionalized violence that has intrinsic unique elements. It is a man made disaster, which is multi-dimensional. War can be   individual as well as a collective form of trauma.  Wars represent a mental health emergency. Mental health is the springboard of thinking and communication skills, learning, emotional growth, resilience, and self-esteem. War trauma can change the parameters of mental health towards the negative side.  The circumstances of the armed conflict can produce a range of emotional and behavioral stress reactions among soldiers and civilians.

In a war situation, combat stress is an inevitable factor. Combat stress is a specific stress factor that can affect the mental and physical health. It is a form of psychological pathology that is resulted from traumatic exposure to battle events. Combat in most cases involved with fear, despair, shock and anxiety. Combat stress is the result of internal and external stresses.

Combat stresses do not come from the enemy action alone. Some stresses are generated from the soldiers own unit leaders and mission demands. Combat stress symptoms and reactions interfere with mission performance. Battle stress affects both the combatants as well as civilians especially living in the war zone.  War disrupts the existing social structure. The major impact of war includes disintegration of psychological well-being. It create a specific calamity sub-culture and often generates vicious cycles that echo even after the war.

War trauma

War can produce incredible acts of heroism and courage and it can produce intense fear and chaos. War trauma is a horrendous experience. As Hanscom (2001) points out war trauma refers to an experience that meets the definition of trauma as described in the DSM IV under PTSD that results from exposure to war conditions. War trauma may also occur and persist within the affected society in the aftermath of war. War trauma survivors may exhibit substance abuse, mistrust in social institutions, flashbacks, suicidal thoughts, antisocial behaviour, and problem with peers.  Their typical responses include sleep disturbances, somatic complaints, anxiety, withdrawal and isolation. The war trauma gives rise to complicated, sometimes uncanny alterations of consciousness and personality. War trauma can alter one's view of life permanently.

The long term effects

War is a multi-layered, multi-factorial phenomenon that can have long lasting affects on the physical and mental wellbeing of the soldiers. Soldiers bear disproportionate consequences of armed conflict. Therefore, equal damage is not seen among the combatants. They sustain physical and mental damage   that are not commonly seen in civilian populations. Ailments such as depression, adjustment disorders, somatoform disorders post-traumatic stress disorders, remain under treated legacies of many soldiers.  In-depth interviews with veterans reveal that their experiences have impacted their personal and family life. As a result of combat trauma, mental health problems, alcohol and drug abuse, physical and sexual violence, child abuse and family disharmony are found among the combatants.

Combat- related PTSD

The circumstances of war can produce a range of emotional, psychological and behavioral stress reactions among the soldiers and officers that can lead to a condition known as combat related PTSD. Post-Traumatic Stress Disorder (PTSD) is described in the DSM4 (Diagnostic and Statistical Manual of Mental Disorders) as the development of characteristic symptoms following exposure to an extreme traumatic stressor. PTSD is marked by symptoms of re-experiencing, avoidance and arousal, was officially delineated in 1980 as a clinical diagnosis within the category of mental disorders.

Combat experiences are often traumatic and it can cause catastrophic stressors outside the range of usual human experience. These events include actual or threatened death or serious injury or threat to soldier's physical integrity or witnessing an event that involves death, injury, or a threat to the physical integrity of another soldier. The person's response to the event must involve intense fear, defenselessness or horror.

Combat- related PTSD is not restricted to the combat experienced veterans. Those who spent time in war zones and were surrounded by death or were put in to life threatening situations may also suffer from PTSD. In the Kulka et al.(1990) study the prevalence of current PTSD for Vietnam veterans was 15% among all veterans. In Sri Lanka, this figure could be 12% or more than that.

Stress factors experienced by the combatants:

1) Physical Stressors

Environmental

Heat, cold

Vibration, noise, blast

Poison, chemicals, radiation

Infectious agents / disease

Bright light, darkness

Skin irritants

2) Physiological stressors

Strenuous work

Sleep debt

Dehydration

Malnutrition

Illness or injury

3) Cognitive stressors

Uncertainty

Deprivation

Unpredictability

4) Emotional stressors

 Fear and anxiety

 Anger & rage producing frustration

 Boredom

 Homesickness

 Interpersonal feelings

Battle Fatigue

Battle Fatigue is a military term used to categorize a range of behaviours resulting from the stress of battle, which decrease the combatant's fighting efficiency. The term "Battle Fatigue" was introduced after World War II and the experts point out that 5%-15% of battle fatigue casualties fail to improve sufficiently to return to duty in the combat zone. The most common signs include, slowing of the reaction time, slowness of thought, difficulty prioritizing, difficulty initiating routine tasks, preoccupation with minor issues and familiar tasks, indecision and lack of concentration, loss of initiative with fatigue and exhaustion.  

Combat shock

Soldiers can go into a state of traumatic shock after exposure to vigorous stress. Shock is a sudden and often intense disturbance and emotional state that may leave soldiers feeling stunned or dazed. The initial traumatic event must have involved actual or threatened death or serious injury or a threat to the physical integrity of self or another person, and the person must have felt fear, helplessness or horror. During the event or immediately after soldiers usually experience numbing, detachment, derealization, depersonalization or dissociative amnesia. As the initial shock subsides, reactions vary from one soldier to another.

War trauma and civilians  

In a military conflict, the first casualties are always the innocent civilians and it is the naked truth of an armed conflict. Nearly 85% of victims killed in WWI were combatants (Graves, 2003). However, "today, some 90% of all people killed in wars are innocent, civilian women and children" (Ehrenreich, 1997; Kolb-Angelbeck, 2000, cited in Graves, 2003, p. 203). In a war today, heavy artillery shelling and aerial bombings take place and because of high tech warfare, innocent civilians suffer.

The Northern conflict in Sri Lanka has led to tens of thousands of people fleeing their native villages. Some families had left to avoid LTTE child forcible recruitments. Many houses in the conflict zone are now in ruins.  Some civilians perished in cross- fires.

Stanley Krippner and Teresa M. McIntyre highlight the psychological impact of war trauma on civilians. They point out that psychological and emotional injuries may be the most enduring effects of war, yet historically they may be the least addressed in terms of rebuilding a society and preventing future violence.

War dislocates the social fabric affecting livelihoods.  According to Professor Daya Somasundaram disasters have an effect not only on individuals but also on their family, extended family, group, community, village and wider society. The civilians of the North and South faced the disturbing effects of the war.

The civilians exposed to war were traumatized in different ways. The effects have longer-lasting consequences than destruction itself. Sometimes unintentionally, parents inflict their psychological baggage on their children and it leads to a vicious cycle of trauma. On most occasions, the impact of war and extreme stress on civilian populations has caused numerous personality changes in them. Psychological responses to these phenomena were expressed as social aggression, alcoholism, family discord, child abuse, self-harm and suicides.

The Psycho-physical Effects

The psychophysical effects of combat have been recorded since the early days of human civilization. From the time of Homer’s ancient story of the battle between the Trojans and the Greeks (1200 BC), military personnel have been confronted by the trauma of war. According to historians, Saul the King of Israel (11th century BC) had abnormal behaviour with inclination towards violence. On one occasion, he went into a brutal rage and tried to kill his son Jonathan.

Alexander the Great (356 BC – 323 BC), who had conquered a large portion of the known world in that era, suffered from combat fatigue. When his forces came near the Indus river, Alexander’s forces were exhausted and refused to march further.

Emperor Ashoka (304 BC- 232 BC) of India experienced a depressive reaction soon after the Kalinga War, after witnessing deaths and destruction. He felt disheartened for his military actions and completely renounced violence and embraced Buddhism.

The Roman Empire, which lasted from 27 BC to 1453, was filled with battle stress. A countless number of soldiers and civilians experienced a great deal of combat related stresses during this time period. Once archeologists discovered an ancient bunker in the Britannic Islands, which was used by the Roman soldiers. They found frescoes that portrayed the isolation, nostalgia, uncertainty, and fear experienced by the soldiers.

The Great Oriental Conqueror Tamerlane (1336- 1405) was highly affected by war stress and demonstrated aggressive and sadistic behaviour. He was fond of building pyramids of human skulls. Once he made a giant pyramid after a war which contained some 40,000 skulls. 

The prophet Nostradamus named Napoleon Bonaparte an Anti Christ. Napoleon’s forces invaded many parts in Europe and North Africa.   His Moscow invasion in 1812 caused heavy damage to the French forces. The French army had to face a cold Russian winter, famine and General Kutuzov’s cannon fire. After his disastrous retreat, Napoleon was sent into exile. He escaped from the island of Elba and engaged in the so- called Hundred Day War.  Finally, Napoleon Bonaparte was defeated by the Duke of Wellington – the Leopard of England. Napoleon went into post combat depression and died in the island of St Helena in 1821 while in exile.

During the US Civil War Dr Mendez Da Costa evaluated 300 soldiers referred to him for a syndrome that he called Irritable Heart. This syndrome was characterized by shortness of breath, palpitations, burning chest pain, fatigability, headache, diarrhoea, dizziness and disturbed sleep.  This condition was later called Da Costa Syndrome. (a syndrome is a group of symptoms that occur together and that are characteristic of a disease or condition).

At the beginning of the World War one  the Effort Syndrome was frequently attributed to cardiac hypertrophy caused by heavy marching , packs compressing the chest. The Effort syndrome was considered to be a  psychoneurosis and not a medical disease. In 1938 Soley and Shock claimed that hyperventilation was responsible for the symptoms of Effort Syndrome.

Until the World War 1 (1914-1918), psychological consequences of war trauma  were considered merely manifestations of poor discipline and cowardice and often the victims were severely punished. Some military records of the WW1 indicate that a considerable number of shell shocked soldiers were given the FP -1 or the Field Punishment Number One.  FP -1 involved the offender being attached to a fixed object for up to two hours a day and for a period up to three months, often put in place within range of enemy shellfire. Dr Charles Myer suspected the psychological factors associated with shell shock.

The Nobel Prize Laureate Ernest Hemingway served in the Lincoln Brigade during the Spanish Civil War that erupted in 1936.  Hemingway saw the horrendous war trauma in Spain and that inspired him to write his famous novel 'Farewell to Arms'.  Anyhow, in later years Ernest Hemingway experienced depression and took his own life. According to the Military Psychiatrist Dr William Pike, half of the Spanish Civil War veterans suffered from severe combat- related stress. At one point, Dr William Pike treated 28 shell-shocked men who were hiding in a wine cellar.

During World War 2 (1939-1945), battle stress was classified as Operational Fatigue or War Neurosis.  Chronic Fatigue Syndrome was evident during World War 2 and most of the symptoms had a somatic nature. It has been estimated that 10% of US servicemen developed combat exhaustion in WW2.  The military authorities were not very empathetic towards war stressed sufferers and on one occasion General George S. Patton slapped and verbally abused Pvt Paul G. Bennet and Pvt Charles H. Kuhl, who experienced battle fatigue.

The term Section Eight was used to identify the victims of psychological effects of war trauma in the Korean War, which continued from 1950 to 1953. Psychiatric evacuations were considerably reduced during the Korean War due to the praiseworthy work of Dr Albert Glass. However in a recent study done by Dr Malcolm Sim and colleagues of Centre for Occupational and Environmental Health, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria,they found anxiety, post-traumatic stress disorder and depression in Korean War veterans 50 years after the war.

In 1965, United States sent troops into South Vietnam to help fight communist guerrillas. US troops fought in hostile territory facing sudden ambushes and booby trap mines. US forces faced defeat and were forced to withdraw from Vietnam in 1975. During the Vietnam War, 2.8 million US servicemen served in Southeast Asia, mainly in Vietnam, and almost one million were exposed to active combat. By the end of the war over 50,000 Vietnam veterans were diagnosed with Combat- related Post-Traumatic Stress Disorder. PTSD has been found in 15% of 500,000 men who were in Vietnam.  It is said 20,000 veterans committed suicide in the war's aftermath.

In 1979 on December 25th, the Soviet Union sent forces to Afghanistan. By 1986, about 118,000 Soviet troops and 50,000 Afghan Government troops were facing perhaps 130,000 Mujahideen guerrillas. Following the conflict over one million Afghans died and the Soviet army lost 14,427 combatants. When Mikhail Gorbachev became the Soviet leader in 1985, he was keen in getting Soviet troops out of Afghanistan. The Soviet withdrawal was completed in February 1989.  Although the Soviet health authorities did not comment on psychological casualties of the Afghan war, there were significant numbers of PTSD victims in the Red Army who fought in Afghanistan. Since PTSD was not recognized in the Soviet Union of that era, the Afghan veterans did not receive proper psychological and psychiatric treatment. Many veterans are still hounded.

The Persian Gulf War (2 August 1990 – 28 February 1991), also known as the First Gulf War was conducted by the Coalition Forces to free Kuwait from Iraqi forces, led by Saddam Hussein. The number of Coalition wounded in combat seems to have been 776, including 458 Americans. Iraq sustained between 20,000 and 35,000 fatalities. The Gulf War Syndrome was evident during the Persian Gulf War and many returning Coalition solders reported illnesses such as headaches, memory loss, fatigue, sleep disorders, intestinal ailments, and unusual loss of hearing. Nearly 150,000 veterans have showed symptoms of Gulf War illness.

According to Toomey R and  Kang HK, Karlinsky  ( "Mental health of US Gulf War Veterans 10 Years After the war",  British Journal of Psychiatry 2007),  found that deployment in the Gulf War was associated with increased levels of mental disorders, psychological symptoms, and a lower quality of life - beginning during the war and persisting at a lower rate 10 years later. Around 700,000 US military personnel were deployed to the Middle East during the 1991 Persian Gulf War. These veterans reported greater psychological symptoms immediately after the war than veterans who were not sent to the Gulf. Ten years later, these cases of depression and non-PTSD anxiety disorders remained significantly more prevalent among the deployed compared with non-deployed veterans. PTSD was over three times more prevalent among deployed veterans.

The War in Afghanistan is an ongoing armed conflict which began on October 7, 2001 and the Second Gulf War, also known as the Iraq War, is an ongoing military campaign, which began on March 20, 2003, with the invasion of Iraq by a multinational force led by troops from the United States and the United Kingdom. There  are massive military campaigns in the present day. These conflicts have produced a large number of psychological casualties. The researchers say nearly 20 percent of military service members who have returned from Iraq and Afghanistan, 300,000 in all, report symptoms of PTSD or major depression. According to a 2005 VA study of 168,528 Iraqi veterans, 20 percent were diagnosed with psychological disorders, including 1,641 with PTSD.

The Sri Lankan conflict, which lasted for nearly three decades, had generated a large number of combatants, members of the LTTE and civilians affected by war trauma, especially PTSD.  Most of these war stressors were not diagnosed sufficiently, and they are not receiving adequate treatment.  Therefore, war stress can affect Sri Lankan society for a long time. To minimize the psychological damage to society, effective measures must be implemented. 

Dr Ruwan M Jayatunge