"You gain strength, courage and confidence by every experience in which you stop to look fear in the face; when you do the thing you think you cannot do."

Eleanor Roosevelt

Combat Veterans Although the Vietnam War began in 1961 and ended in 1975, hundreds of Vietnam combat veterans continue to experience flashbacks and other PTSD symptoms.   Ten to twenty percent of soldiers exposed to combat in Iraq and Afghanistan are predicted to experience PTSD symptoms (Boal; 2007).

According to current research studies, soldiers who serve in combat zones have the highest levels of PTSD of any profession.  Physicians treating solders who fought in World War I and II were among the first professionals to recognize and write about the extremely debilitating symptoms that exposure to work-related trauma (i.e., combat) could have. Initially referred to as “shell shock”, “war neurosis”, “hysterical disorders”, and “neurasthenia”,  in later years symptoms resulting from serving in combat were labeled “battle fatigue’ and “combat fatigue”.  During WWI and WWII, combat soldiers who developed these disorders were often regarded as defective even by generals.  During World War II, General Patton was disciplined for slapping a soldier who appears to have been experiencing PTSD and allegedly calling him a coward (Pastorella, 1991).  Recognition that serving in combat could traumatize military personnel was, in all probability, the first professional acknowledgment of job-related trauma. (Van der Kolk, 2000).

However, it was not until health professionals began to deal with large numbers of traumatized Vietnam Veterans during the late 1960’s and 1970’s that the term Post Traumatic Stress Disorder (PTSD) was created to describe the symptoms that these soldiers were experiencing; PTSD was added as a diagnostic category to the manual used by physicians and therapists in 1980 (Diagnostic and Statistical Manual of Mental Disorders (DSM III) (van der Kolk, et. al., 1991).   Soldiers who served in combat and became POW’s have been particularly traumatized.  In studying 262 men who had been POW’s in World War II or the Korean War, 53% had lifetime incidents of PTSD, with 29% having current PTSD.  POW’s who were the most severely traumatized (those who were in Japanese POW camps) had lifetime PTSD rates of 84%.  Fifty six percent of Dutch WWII Resistance Veterans still living continue to be in PTSD (Falger, et. al.; 1992).  Despite their high rates of PTSD, few of these men had sought mental health treatment (Engdahl, et. al.; 1997).

The National Vietnam Veterans Readjustment Study found the estimated lifetime prevalence of PTSD among American Vietnam theatre Veterans (those who served directly in combat) to be 30.9% for men and 26.9% for women (who were mostly registered nurses).  An additional 22.5% of these men and 21.2% of the women have had partial PTSD at some point after serving in the war.  At the time of the study, 1986-1988, “15.2% of all male Vietnam Veterans and 8.1% of all female Vietnam theater veterans remained in PTSD” (Kulka, et. al, 1990; Kessler, et. al., 1995), with those serving in heavy combat having the highest rates, i.e., 30% (King, Keehn & King, 2002). In a research study in which 1,703 men (out of 5877 surveyed) reported a traumatic event, those who reported their traumatic event as involving military combat were more likely to have lifetime PTSD, to be unemployed, fired from a job, divorced and physically abusive to their spouses than men who reported other types of traumas (Prigerson, Maciejewski & Rosenheck, 2001).  Veterans exposed to heavy combat with prior histories of trauma reported higher levels of PTSD than veterans exposed to heavy combat without a prior trauma history.  This difference was not found when comparing Veterans exposed to low levels of combat (King, Keehn & King, 2002).  The insight gained from studying combat veterans of previous wars can be helpful in treating combat soldiers returning from service in Iraq and Afghanistan.

Research on monkeys exposed to inescapable shock, has provided additional insight into why service in Vietnam was so traumatizing (van der Kolk, Boyd, Krystal & Greenberg, 1984).  Soldiers assigned to serve in combat areas in Vietnam were frequently not serving on a voluntary basis.  The draft was in effect during the Vietnam War and those who refused to serve without legal justification were jailed.  Furthermore, the option to quit the military or to leave Vietnam and return home did not exist, as it does in most other jobs with high levels of job-related trauma.  Soldiers were typically assigned to serve in Vietnam for a year. In many aspects, serving in combat situations in Vietnam (and in Iraq or Afghanistan) may, for some soldiers, be similar to a caged animal experiencing inescapable shock or, in a similar way, an abused child in a home where there is extensive violence: the lack of control, inability to escape, injury, difficult living conditions, constant terror and the perceived lack of outside support.

PTSD rates for soldiers returning from combat duty in Iraq or Afghanistan are running at between 10-15% (The New England Journal of Medicine; 2005).  This high level of PTSD is predictable: most of these soldiers tend to be young; serving in a culture and environment that is foreign to them where the living conditions may be quite primitive.  Although e-mail contact is allowed sporadically, these soldiers have been separated from their families and non-military friends.   The majority of these soldiers are being deployed for months and often for more than one tour in which they are repeatedly exposed to situations involving death and violence.  Many soldiers repeatedly experience intense levels of fear and become progressively more traumatized with each incident.

In addition, buddies and solders serving in their unit may be killed or injured in their presence, often in a very violent manner.  The common use of bombs by the enemy leaves only bloody pieces of a body…pieces of someone they may have laughed with only hours before.   Trauma can be intensified if the soldier is assigned to clean up the body parts of these friends---a horrific assignment that would give nightmares to all but the coldest of men or women.  These soldiers may communicate with the relatives of friends who were killed and/or attend their funeral and, if they are in full dress uniform, expected to show no emotion.  When friends and peers are killed or mutilated day after day, survivor guilt is common.

Soldiers may kill an enemy and view the enemy dying; some kill children, either by accident or because the child has a weapon and would kill them if given the chance.  Under any circumstances, killing a child is abhorrent and life-altering to almost any soldier.  Exposure to the bodies of both enemy soldiers and innocent civilians is common.  Some soldiers have been mistaken for the enemy and attacked by their friendly fire. Sleeping conditions may be such that little sleep is achieved; food may be strange and unfulfilling.   Lack of control plays an important role in the development of PTSD symptoms.  It is not unusual for a soldier to be deployed to combat areas without volunteering and they may be re-deployed more than once.  Most professions, even those with exposure to the most violent of traumatic incidents, give employees not only the freedom to quit (resign), but the ability to return home for regular breaks, offering at least some temporary relief from the stressors of the job.  In general, having time away from the job allows these workers daily access to a support system, commonly their family or friends  (Fire fighters, who may be required to stay in the station for 24-hour shifts, are an exception, but they generally develop a strong support system at the firehouse, in addition to their family support.)  There are other exceptions, of course, such as “Search and Rescue Teams” assigned to foreign countries for brief periods.  However, these workers usually volunteer, and are rarely exposed to the combination of the level of violence and length of time typical of soldiers serving in combat.  Experiencing a lack of control and feeling trapped may thus become a companion to their fear.

These soldiers are constantly reminded that even if they are not killed, day after day they risk injury that could be life-altering and lead to their becoming permanently handicapped.  A number of combat veterans who have seen Dr. Davis for treatment commented that, every day that they served in Iraq they told themselves, “Today may be the day I die.”

Humans are designed with a number of systems that activate when survival is threatened.  These systems make muscles stronger; re-direct blood flow to muscles and change heart rate, perception and brain function to deal with the threat.  A number of hormones are released to activate these systems, such as adrenaline.  Given that soldiers in combat are constantly at risk of attack and dying, their bodies turn on their survival systems; these systems usually remain “on” during the entire length of their service in the combat zone.

These systems helped to keep the soldier alive during their combat service; they served their intended purpose.  However, when the soldier returns to a non-combat situation, it is somehow expected that his or her body will automatically turn these systems off immediately and completely …the systems that for months helped to keep him or her alive day after day for months on end.  The dive to the ground that saved the soldier’s life when fired upon or a bomb exploded becomes embarrassing when it occurs back home at the sound of a car backfire.

The military is beginning to recognize that PTSD is a normal and predictable response to serving in combat; a continuation of a response that helped to keep the soldier alive.  Critics assert that the number of soldiers diagnosed with PTSD is far lower than the actual number of those experiencing symptoms.  In funding the Iraq War, “no money was allocated for mental health causalities” (Boal; 2006).  Given that so many soldiers have been traumatized by their military service, the resources and funding to provide these soldiers with treatments which are effective should be a priority.

Incidents Most Likely to Lead to PTSD in Soldiers Serving in CombatIncidents Include:

• Witnessing the death of a fellow soldier or viewing the body at the scene, especially when the victim was a friend or known personally.  When a soldier is physically close to the soldier who was killed, even talking to him or her as it happened, the impact of their death increases.  Trauma is often increased if the soldier believed he or she should have protected the person who died, or if the dead soldier had taken the place of the soldier, such as instances in which a soldier who is sick is replaced on patrol by another soldier who is killed during this patrol.  When a soldier imagines him or herself as the dead soldier, then visualizes the impact that their death would have on those they love, the traumatic impact of this event can be even greater.

• A reasonable belief that death or critical injury is imminent and certain.  Experiences in which death would have occurred, such as situations where a soldier tells him or herself that they would be dead if the bullet had moved in a slightly different trajectory, or the bomb would have gone off slightly sooner or later, or they had not moved their head right before the shot.

• A soldier accidentally kills or wounds civilian they perceive as innocent, particularly when the victim is a child.

• A soldier believes that his or her actions failed to stop an enemy from injuring or killing another soldier or soldiers or caused their death or injury. 

• Killing or wounding a child or young teenager, even if the life of the soldier was threatened by the person injured or killed.  If large numbers of children are killed as the result of a particular action such as bombing a building that turned out to be an orphanage filled with children, the probability of PTSD is substantially increased.

• Viewing the body of a child victim, particularly if the soldier has children and even more so if the soldier’s child is the same age and sex of the victim or if the body of the child is similar in some other way to the soldier’s child

• When the death of a soldier leads to interaction with grieving family members or friends, finding out personal information about their life, viewing personal items in their home or community.  The greater the personalization of a victim, the greater the chance of the incident being traumatic.

• Particularly bloody or gruesome scenes. Being assigned to clean up body parts of a scene in which a friend was brutally killed or blown apart.

• Combat in which high numbers of fellow soldiers are killed or wounded can lead soldiers who lived without injury to feel guilty and this survivor guilt can lead the soldier to expose him or herself to situations in order to be killed so they can join dead comrades.

• Following exposure and/or involvement in a traumatic combat incident, inappropriate responses of commanding officers can significantly increase the traumatic impact.