Sunday, June 11, 2017

Post Combat Depression (PCD)

Dr Ruwan M Jayatunge

The component of depression was evident to Dr. Mendez Da Costa who introduced the term Irritable heart during the US Civil War and Lt Col (Dr) Fredric Mott who coined the term Shell Shock during the World War one. Sometimes depression is obvious among the servicemen who were exposed to traumatic combat events. In addition to depressive symptoms they can have anxiety related features with survival guilt.
In common terms depression is a medical condition leading to persistent feelings of worthlessness, hopelessness, guilt, agitation and indecisiveness. Depression can occur following negative life event, physical illness such as thyroid imbalance or diabetes mellitus. Post combat depression (PCD) usually takes place mostly as a result of traumatic combat experience with negative cognitive interpretations.

A depressed soldier experiences deep unshakable sadness and diminished interest in most of the personal as well as military activates. Depression can dramatically impair a soldier’s ability to function in field situations. A soldier who develops severe depression may appear so confused frightened and unbalanced.
Depression is a mood disorder in which pathological moods and related vegetative and psychomotor disturbance dominate the clinical picture. The term Post combat depression has been used for the first time in the publication “PTSD Sri Lankan Experience”(1) and described as a group of symptoms such as anhedonia, low energy , decreased libido, reduced life interests, somatic pain, alienation, numbing, self blame and survival guilt that is experienced by combat solders after exposing to traumatic battle events. Depression causes a disturbance in a soldier’s feelings and emotions. They may experience such extreme emotional pain that they consider or attempt suicide.

Learned Helplessness in the Battle Field
Seligman (1975) was studying the effects of learned helplessness which is associated with depression. He studied the series of escape mechanism of doges when exposed to electric shock. In this study many doges did not attempt to escape although there were escape paths. Instead they suffered eclectic shocks and remained helplessly. Seligman stated that learned helplessness is a factor in depression. The learned helplessness model proposes that the depressive posture is learned from past situations. Soldiers in the battle field act in certain way as the Seligman doges when exposed to traumatic events. Sometimes they do not take any positive measures to change their situation.

Case Study 1
Private S has served 7 years in the Army and once sustained minor injuries as a result in an incoming mortar. He was diagnosed with depression in 2002. For a number of years private S unconsciously maintained his depressive symptoms. He always felt there was no happiness around him. Constantly he complained of low self fulfillment, insomnia, feelings of pessimism, loss of interest in ordinary activities despite the medication and counseling. He has had acquisition of depression related symptoms and this learned helplessness was liquidated by changing his life philosophy.

Cognitive Triad
Beck (1979, 1983) hypothesized that depression prone individuals possess negative self schemata which he describes as “cognitive triad”(2). Combatants with PCD often  have negative view of themselves may be as a result of the acts that they have committed in the battle field or may be due to low recognition of post military service by the society. They see their environment as overwhelming filled with obstacles and failure. Also they have the pessimistic outlook of the future.

Case Study 2
Private R shot his arm in the battle field in order to get evacuated. After the discharge from the hospital he was sent for light duty. No disciplinary actions taken due to sympathy grounds. Private R constantly devaluated himself as a worthless creature with full of guilt. He always felt that the world is filled with obstructions and these obstacles prevent him to grow. Being depressed Private R had a negative and critical ideas about future.

Case Study 3
Sergeant T retired from the military after serving 22 years. He was depressed due to lack of recognition. He felt neither the military nor the society gave him the due respect for the services he has rendered. He felt helpless, unworthy and discarded. Sergeant T had a negative attributional  style and later found with full blown melancholic manifestations of a depressive disorder. He was treated with cognitive restructuring.

Survival guilt
Many soldiers become emotionally shattered witnessing the death of their buddies. Sometimes they hold responsibility for the deaths of their friends. These solders always question their conscience. Often they say to them selves it’s unfair for me to live since I could not save their lives or they have gone because of my error, I don’t deserve to live etc. These are the common self blame patterns that can be seen among the soldiers with PCD. They carry the memories of their dead comrades for decades.

Case Study 4
Lance corporal N witnessed the death of his friend following an artillery attack. His other friend was badly wounded by this attack. Lance Corporal N carried his buddy to the nearest medical point. On the half way the friend died leaving severe guilty feeling in him. He is depressed and blames himself for not rescuing the buddy. 

Case Study 5
Corporal G sustained a gun shot injury to his left thigh in an ambush and he fell down. He was bleeding and others could not help him due to heavy fire. One of his batch mates came to help him. The moment his friend carried him for rescue the enemy fired towards them. One bullet went through the batch mates head killing him instantly. Corporal G was laying on the ground for nearly four hours with the friend’s body. Eventually a group of Special Forces men attacked the enemy and rescued him. Today corporal G has intrusions about his friend’s death and severe survival guilt.

Case Study 6
Sergeant L who was a former commando went in to depression as a result of survival guilt. Once he went with a four man team for a reconnaissance. Unexpectedly they were attacked by the enemy. Although sergeant L managed to escape the attack, the others became wounded. They were bleeding heavily and he had no way to take them back or get help from outside. Sergeant L had no other alternative but to leave his friends behind the enemy lines. After he escaped he never heard anything about them. Depressed and blaming himself sergeant L still carries the burden of survival guilt. 

Misconduct stress behaviors as a result of PCD
Many depressed soldiers use natural defenses against self attacking shame by striking out at others, attacking others by being critical, sarcastic or abusive. Alcohol and substance abuse can be a prevailing feature of PCD.

Interpersonal relationships
Depressive behavior clearly has a powerful interpersonal impact. The affected servicemen have deteriorated interpersonal relationships in the battle field. On certain occasions combatant’s family members too feel this distance and coldness.

Self harm and suicide
Depression represents a masochistic life style. Soldiers with post combat depression suffer from lack of assertion and outwardly directed aggressiveness. Aggression turned inward mechanism is a universal explanation for depressed behavior. Freud’s concept of aggression turned inward model or depressed affect is derived from retroflexion of aggressive impulses directed against an ambivalently loved internalized object was actually formulated by his student Carl Abraham.

As the psychoanalyst Carl Menninger elaborates suicide is a murder in 180 degrees. Soldiers are taught to be aggressive. Killing is a part of military training. Therefore aggressive tendency and will to kill the enemy is an accepted component in the military culture. Sometimes this outward directed aggression turns 180 degrees and PCD soldiers shoot themselves.

Frequently soldiers with post combat depression go in to various types of self harm including risk taking behavior.  In the height of depression they can take their own lives. Very often these soldiers use their   weapons to commit suicide.

Case study 7
Private K was exposed to numerous traumatic battle events and he had repeated thoughts of suicide. While on guard he shot himself with his firearm. The bullet went through his abdomen damaging the spleen. He was rushed to the hospital and laporatomy was performed. The doctors at the Palaly hospital were able to save his life. Later private K was found with full clinical picture of depression.

Depressive Fugue States
Undiagnosed and untreated depression can lead to many complications in the battle field. In the height of the depression combatants with PCD can go in to fugue states. When they are under fugue states they become numbed and can be disoriented.

Case Study 8
Private P was found by a group of soldiers when he was wandering and heading towards the enemy lines. When questioned he had no idea how he came out if his bunker. Also there was no trace of his weapon. Probably he must have dropped it in the jungle. When he was referred for a psychiatric assessment he denied any kind of substance abuse. There was no history of dissociative disorder. But he was depressed following the deaths of his platoon members. He saw how they died as a result of the enemy attacks. He was helpless. Later his friends were buried in the jungle. He could not forget the dreaded events of the battle. Private P was depressed. His depression was undiagnosed and untreated until he went in the depressive fugue.

Physical injuries, Disabilities and PCD
A large number of soldiers who sustain physical injuries and become disabled can go in to post combat depression. This category describes depression that occurs in response to a major life stressor or crisis. Stressful events such as physical injury and disability often appear to be triggered by the temperamental instability that precedes clinical episodes.

Case Study 9
Lieutenant R sustained abdominal injuries following a mortar blast in 1996. He was hospitalized and performed a number of operations in order to save his life. Although he recovered from his physical injuries he became gloomier. He had feelings of hopelessness and pessimism, lost of interest and pleasure in day today activities, loss of appetite and energy, cognitive impairments, difficulty in sleeping, self blame, self pity and repeated thoughts of death. Lt R felt that he was used by the military and thrown away. He could hardy adjust to the military rules and regulations. Several times he became AWOL. He has a pessimistic view on his military career. He was diagnosed as having Depressive disorder in 1998.

Combat Psychiatrists/ Psychologists generally diagnose depression based on symptoms and other criteria. As screening tests BDI or Beck’s Depression Inventory or Hamilton Rating Scale (which consists about 20 questions that assess the individual for depression) can be used. Apart from common depressive signs PCD can have other trauma related features such as intrusions, hyper-arousal and survival guilt. Many combatants with PCD have negative interpretation of combat events and pessimistic outlook on the post combat environment.  To diagnose PCD combat history and combat records should be assessed.

Differential Diagnose
Post Combat Depression has to be distinguished from PTSD, Adjustment Disorder, Acute Stress Disorder, Bipolar Affective disorder and common depression. For PTSD  DSM-4 offers special criteria  such as the history of life threatening catastrophic event that involved fear and haplessness, intrusive recollections, avoidance , hyperarousal and psychosocial impairments. Adjustment disorders generally develop in a month or so after significant life change and resolves within 6 months. Most patients typically manifest depression or anxiety symptoms. According to DSM-4 Acute Stress Disorder occurs within 4 weeks of a life threatening traumatic event lasting for at least 2 days and resolving within that 4 week period.  Bipolar Affective Disorder involves episodes of both mania and depression. The person’s mood swings from excessively high and irritable to sad and hopeless and with periods of normal mood in between. The difference between common depression and PCD is in Post Combat Depression traumatic combat history, survival guilt and negative interpretation of battle events are included.

PCD can be treated with medication and psychotherapy. Antidepressants are effective in PCD. The major antidepressant drug classes the selective serotonin reuptake inhibiters (SSRIs), Tricycles and MAOIs. A new group of drugs generally referred to as designer antidepressants have been developed to target specific brain chemicals believed to be involved in depression. These designer antidepressants are too useful in treating PCD.
Psychotherapy is an effective treatment for PCD. Cognitive Behavior Therapy or CBT focuses on identification of distorted perceptions that patients may have of the combat and themselves changing these perceptions and discovering new patterns of action and behavior. PET or Rational Emotive Therapy helps to change the irrational and illogical thoughts such as survival guilt held by the combatants. RET is an approach that focuses on altering client’s patterns of irrational thinking to reduce maladaptive emotions and behavior.

EMDR is very effective in treating PCD. EMDR is a complex treatment approach that combines salient elements of the major therapeutic schools such as cognitive, behavioral, psychodynamic and inter-actional. It is a specific treatment approach which helps a person quickly resolve the emotional aftermath of traumatic experiences. Cognitive interweave (Shapiro 1995) which is used during EMDR helps to liquidate the negative cognitive belief system held by the combatants with PCD.


  1. Good post Dr. Ruwan

    I think Sri Lanka & it's Armed forces would be the best place to do such research. Well done. Better you could post a brief post in Sinhala as well, for common readers in a simpler language.


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