A BRIEF HISTORY OF P.T.S.D.

Echo Co., 2nd Battalion, 26th Regiment., 9th Marine Expeditionary Brigade, 3rd Marine Division Marines moving up to hill 861 from hill 861a in late March or early April, 1968, Khe Sanh, South Vietnam. This author was part of that move. This picture of Echo. Co. was taken by Cpl. Tommy Eichler. Used by permission.

Khe Sanh Marine, Michael E. O’Hara, has written of his combat experiences and the Bible verse quoted above. “When we mixed it up on 30 March with Charlie, the chain of events of that day would sear a man’s mind for eternity. There was much carnage that day of course. I still wonder how human beings can continue to do that to each other but seem to continue to find ways. But what has stayed with me always, what makes me so PROUD, is the heart and courage these young new friends of mine displayed that day. I have said many, many times over the course of my life the following. It is one thing to read in our Bibles the verse in John 15:13 which says “Greater love hath no man than this, that a man lay down his life for his friends.” It is an entirely different thing to actually witness young men, on more than one occasion, do precisely that. It will humble you beyond description. It is why so many of us, myself included, will always defend their Honour.”

The list of 2nd Battalion, 26th Regiment Marines & Corpsmen (below) killed in action (KIA) at Khe Sanh serving on hills 558 and 861a, from 16 Jan. ’68, the day we left Phu Bai, until 12 Apr. ’68, when we left Khe Sanh.

LTJG Robert R. Brett, CHC USNR - 1/Lt. Fernando Distefano USMC - 1/Lt. Alfred Jordan USMC - S/Sgt. Glenn H. Calvin USMC - Sgt. Billy R. McCall USMC - HM2 Charles T. Langenfield USN* - Cpl. Carlos C. Aguirre USMC - Cpl. Herman A. Lohman, Jr. USMC - Cpl. Artis W. Meadows, Jr. USMC - Cpl. Edward A. McGrath USMC - Cpl. George A. Pruitt USMC - Cpl. Donald R. Schroeder USMC - Cpl. James M. Trimble USMC - Cpl. Kenneth R. Williams USMC - HM3 Russell W. Scarborough USN - LCpl. Lionel R. Crase USMC - LCpl. Julius C. Foster USMC - LCpl. Gerrie G. Jeffries USMC - LCpl. Eugene M. Johnson, Jr. USMC - LCpl. Tyrone F. Lamitie USMC** - LCpl. Joseph A. Mollettiere USMC - LCpl. Max A. Nelson USMC - LCpl. Manuel V. Romero USMC - LCpl. John M. Snyder, Jr. USMC - LCpl. Louis F. Staples USMC - LCpl. Harold A. Strausbaugh USMC - LCpl. James R. Wells USMC - LCpl. Gilbert Wiley USMC - LCPl. James A. Wood USMC - LCpl. William L. Yohn USMC - HM Roger M. Nelson USN - HM James C. Delaplane USN* - HM Joseph Lopez USN* - HM Donald A. Labonte USN - Pfc. Gilbert J. Adams USMC - Pfc. Thomas J. Bayes USMC - Pfc. Jack C. Bagard USMC - Pfc. Clifford G. Borrell USMC - Pfc. Francis Carter USMC - Pfc. Alexander S. Chin USMC - Pfc. Allen J. Gaines USMC - Pfc. David A. Cramer USMC - Pfc. Melvin L. Dolby USMC - Pfc. Arthur L. Edmonds USMC - Pfc. Adolpo A. Gomez USMC - Pfc. Earl W. Heifner USMC - Pfc. Edward V. Masters USMC - Pfc. Rickey J. Marson USMC - Pfc. Clifton Moses USMC - Pfc. Anthony J. Pepper USMC - Pfc. Lloyd G. Seal USMC - Pfc. Hector L. Semidey USMC - Pfc. Alan R. Smith USMC - Pfc. Charles R. Stephenson USMC** - Pfc. Ernest V. Taylor USMC - Pfc. Michael V. Wright USMC - Pfc. Gilbert Zerbst USMC - Pvt. B.M. Hillimon USMC - Pvt. John F. Quattlebaum USMC

* LCpl. stands for Lance Corporal, E-3.

* Designates one of three corpsman KIA by a 122mm rocket, one day before we left Khe Sanh at hill 558.

** Designates a close Marine buddy, KIA at same moment on Feb. 5, 1968.

All Bible quotes are from the 1995 NASB translation unless otherwise stated.

All other pictures in this work are from the public domain

* I want to remember John Cook, a good buddy from Plt. 1007 at MCRD, San Diego, CA, KIA.

B.C.

India (5,000 B.C.)

However, the Indian literature mentioned combat trauma around 5000 BC. The description of a PTSD-like syndrome is seen in the Ramayana, although it was not described as PTSD or by any other similar name. Ravana’s brother Marrich was having symptoms of PTSD after Lord Rama’s arrow grievously hurt him, and he was almost dead. This traumatic event threatened his physical integrity. He developed all the symptoms of PTSD, like hyper-arousal, re-experiencing the circumstances, and avoidance. He also gave up his natural work of harassing the monk and engaged in meditation and austerities. His symptoms lasted for many years till Lord Rama killed him while he was masquerading as a golden deer to deceive Sita. In another ancient epic, Shrimad Bhagavatam, Maharshi Ved Vyasa described the symptoms of Generalized Anxiety Disorder (GAD). The demon King Kansha developed GAD-like symptoms when Lord Krishna killed all his demons and threatened to kill him. He developed symptoms of GAD, like excessive worry about the attack from his arch-foe Krishna, difficulty in concentration, and difficulty in falling asleep. Like Marrich, the symptoms of Kansha also lasted until Lord Krishna killed him.1

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1 Hitesh C. Sheth, Zindadil Gandhi, and G. K. Vankar, "Anxiety disorders in ancient Indian literature," Indian Journal of Psychiatry 52, 3 (Jul-Sep 2010): 289–291.

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In the Indian epic poem Ramayana, likely composed around 2,500 years ago, the demon Marrich experiences PTSD-like symptoms, including hyper-arousal, reliving trauma, and avoidance behavior, after nearly being killed by an arrow. Marrich also gave up his natural duty of harassing monks and became a meditating recluse.2

Many years after that traumatic incident, when Ravana asked Marrich to help him abduct Rama’s wife Sita, he stared blankly at Ravana. His mouth became dry on hearing the name of Rama. He began to lick his lower lip with his tongue. His heart was filled with terror and he began to tremble. He almost became unconscious (Verse: 22, 23, 24, Chapter 36 Aranyakand, Valmiki Ramayana), (symptoms of hyper-arousal). 

He described Rama’s strength to Ravana and forbade him to abduct Sita. He said, “I know Rama’s strength. It is not prudent to fight against him. If you wish, you can fight against him alone but don’t involve me in that fight. If you want to see me alive, don’t discuss Rama in front of me.”

Unknown author. Rama is depicted blue-skinned and carrying a strung bow with a quiver full of arrows on his back and a single arrow in his right hand. 1820 (? Watermark is 1816).3

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2 "PTSD and Shell Shock,"History, History.com Editors, Updated: March 28, 2023. 

3 This is a faithful photographic reproduction of a two-dimensional, public domain work of art. The work of art itself is in the public domain for the following reason: This work is in the public domain in the United States because it was published (or registered with the U.S. Copyright Office) before January 1, 1929.

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He also described his own symptoms that he developed after Rama’s arrow hit him (Verse: 19, 20, Chapter 39, Aranyakand, Valmiki Ramayana). He said, “Now, in every tree, I see Rama with bow and arrow, wearing black deer skin. Lord Rama appears to me like the God of Death (Yama). Sometimes I see thousands of Rama and I am filled with terror (Verse: 15, Chapter 39 Aranyakand, Valmiki Ramayana).

"When I sit in solitude, I see nothing but Rama. Sometimes I see Rama in my dreams and I often lose consciousness. Sometimes I think that Rama is pervading the whole universe.” (Verse: 16, 17, and 18, Chapter 39, Valmiki Ramayana). 

In Goswami Tulsidas’s ‘Ramcharit Manas’, Marrich says to Ravana, “I see Rama and his brother Laxmana everywhere. Both are extremely valiant and cannot be defeated in war.” (Verse 24, Aranyakand, Ramcharit Manas), (symptoms of re-experiencing). 

He further adds, “I am unable to hear the name of things which starts with the letter ‘R’. When I hear that, I begin to tremble, because the letter ‘R’ reminds me of Rama. So I avoid Rath (chariot), Ratna (gems) and other things that begin with ‘R’. (symptoms of avoidance) (Verse 18, Aranyakand, Valmiki Ramayana).4

Assyria (3200 B.C.)

The Assyrians left very detailed accounts of their military conquests and battles, according to a 2015 study.

Some of these medical texts document the trauma and injuries that Assyrian soldiers suffered during these campaigns. Various forms of protective shields, helmets, and iron-scaled armor reached their highest technological level in the Assyrian period. Unfortunately, offensive weapons also reached their highest effectiveness during that period.5

Relief depicting Assyrian archers attacking a besieged city, most likely in Mesopotamia. An Assyrian soldier holds a large shield to protect two archers as they take aim. From the Central Palace in Nimrud and now in the British Museum, London. Circa 728 BC. [[File:Assyrian archers.jpg|Assyrian_archers]] Public domain.

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4 Aranyakand, Valmiki Ramayana. 8th ed. (Gorukhpur: Geeta Press, 1992), 369-374, in Sheth, Gandhi, and Vankar, "Anxiety disorders in ancient Indian literature."

5 JoAnn Scurlock, and Burton R. Andersen. Diagnoses in Assyrian and Babylonian Medicine. Ancient Sources, Translations and Modern Medical Analyses (Urbana: University of Illinois Press, 2005).

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"A new study of ancient Assyrian medical texts from Mesopotamia, in what is now Iraq, shows that Assyrian doctors were diagnosing and treating psychological conditions related to war. One assumption ancient Assyrians made was that the gods allowed dead people’s spirits to punish living people. So warriors who experienced mental trauma were thought to be under attack by the ghosts of people they killed in battle. Today we call this mental trauma from war and other difficult experiences post-traumatic stress disorder, often shortened to PTSD."6

Epic of Gilgamesh

For example, in the Epic of Gilgamesh, the earliest surviving major work of literature (dating back to 2100 B.C.), the main character, Gilgamesh, witnesses the death of his closest friend, Enkidu. The trauma of Enkidu’s death tormented Gilgamesh by recurrent and intrusive recollections and nightmares related to the event. 

    1.     2.7

1. After the gods kill his best friend, Enkidu, Gilgamesh goes out on an adventure to secure the secret to an immortal life. Hopes to use the knowledge gained to not only keep him immortal but to also bring Enkidu back from the dead. Image: Representation of Enkidu (2027-1763 BCE), a creation by the gods to King Gilgamesh from treating his people cruelly.8

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6 Mark Miller, "Weapons and tactics change, but PTSD goes back millennia," Updated 27 January, 2015.

7 This is a newly discovered partially broken tablet V of the Epic of Gilgamesh. The tablet dates back to the old Babylonian period, 2003-1595 BCE; Neo-Babylonian period according to the edition in F. Al-Rawi et A. R. George, "Back to the Cedar Forest: The beginning and end of Tablet V of the Standard Babylonian Epic of Gilgameš", Journal of Cuneiform Studies, vol. 66, 2014, pp. 69-90. From Mesopotamia, Iraq. The Sulaymaniyah Museum, Iraq. 

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My friend, whom I love deeply, who went through every hardship with me

Enkidu, my friend, whom I love deeply, who went through every hardship with me,

the fate of mankind has overtaken him.

Six days and seven nights I mourned over him and would not allow him to be buried

until a maggot fell out of his nose.

I was terrified by his appearance(!), I began to fear death, and so roam the wilderness.

The issue of my friend oppresses me, so I have been roaming long trails through the wilderness.

The issue of Enkidu, my friend, oppresses me, so I have been roaming long roads through the wilderness.9

Later, in a 440 B.C. account of the battle of Marathon, Greek historian Herodotus describes how an Athenian named Epizelus was suddenly stricken with blindness while in the heat of battle after seeing his comrade killed in combat. This blindness, brought on by fright and not a physical wound, persisted over many years.

Other ancient works, such as those by Hippocrates, describe soldiers who experienced frightening battle dreams. And outside of Greco-Latin classics, similar recurrent nightmares also show up in Icelandic literature, such as Gísli Súrsson Saga.

Greece

Homer (850 B.C.)

In book XXIV of Homer’s Iliad, written about 850 B.C., Achilles becomes prey to recollections about his friend Patroclus, who died in combat (book XVI). These recollections are recurrent and cause very disturbed sleep (Homer, 1950): 

“But Achilles went on grieving for his friend, whom he could not banish from his mind, and all-conquering sleep refused to visit him. He tossed to one side and the other, thinking always of his loss, of Patroclus’ manliness and spirit... of fights with the enemy and adventures on unfriendly seas. As memories crowded in on him, the warm tears poured down his cheeks.”

Achilles mourning Patrocles, John Flaxman, 1795. (This work is in the public domain in its country of origin and other countries and areas where the copyright term is the author's life plus 100 years or fewer.)

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8 If you need to use any image from my Wikimedia Commons uploads, please feel free, but remember, you have to credit me properly and in full, as all of my images on Wikimedia Commons carry a "CC BY-SA 4.0 international" license. I don't grant permission to use my images for commercial purposes. To credit me, use the following formula: Photo credit: Osama Shukir Muhammed Amin FRCP(Glasg), CC BY-SA 4.0, via Wikimedia Commons (insert the URL of the image here).

9 The Epic of Gilgamesh, Translated by Maureen Gallery Kovacs.

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Plutarch

 2 But Marius himself, now worn out with toils, deluged, as it were, with anxieties, and wearied, could not sustain his spirits, which shook within him as he again faced the overpowering thought of a new war, of fresh struggles, of terrors known by experience to be dreadful, and of utter weariness. He reflected, too, that it was not Octavius or Merula in command of a promiscuous throng and a seditious rabble against whom he was now to run the hazard of war, but that the famous Sulla was coming against him, the man who had once ejected him from the country, and had now shut Mithridates up to the shores of the Euxine Sea. 

3 Tortured by such reflections, and bringing into review his long wandering, his flights, and his perils, as he was driven over land and sea, he fell into a state of dreadful despair, and was a prey to nightly terrors and harassing dreams, wherein he would ever seem to hear a voice saying:—

“Dreadful, indeed, is the lions’ lair, even though it be empty.”10

And since above all things he dreaded the sleepless nights, he gave himself up to drinking-bouts and drunkenness at unseasonable hours and in a manner unsuited to his years, trying thus to induce sleep as a way of escape from his anxious thoughts. 4And finally, when one came with tidings from the sea, fresh terrors fell upon him, partly because he feared the future, and partly because he was wearied to satiety by the present, so that it needed only a slight impulse to throw him into a pleurisy, as Poseidonius the philosopher relates, who says that he went in personally and conversed with Marius on the subjects of his embassy after Marius had fallen ill.11

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10 A hexameter verse of unknown authorship.

11Plutarch. Parallel Stories. http://www.theoi.com/Text/PlutarchParallelStories.html (accessed July 30, 2018).

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A.D.

1003 Alderman Elfric 

In 1003, the first millennium after Christ's birth, the English fought the Danes. The English commander, Alderman Elfrick, apparently became violently ill and could no longer lead his men. His vomiting was perhaps the onset of P.T.S.D. 

"Then was collected a very great force, from Wiltshire and from Hampshire; which was soon ready on their march against the enemy: and Alderman Elfric should have led them on; but he brought forth his old tricks, and as soon as they were so near, that either army looked on the other, then he pretended sickness, and began to retch, saying he was sick; and so betrayed the people that he should have led: as it is said, "When the leader is sick the whole army is hindered."12

14th Century Jean Froissart13

“Jean Froissart (1337? -1400/01) was the most representative chronicler of the Hundred Years’ War between England and France.” In 1388, Froissart lived at the court of Gaston Phoebus, Comte de Foix. He wrote of the case of the Comte’s brother, Pierre de Beam. Pierre would not sleep near his wife and children since he was in the habit of waking at night, taking hold of a “sword to fight oneiric enemies.”14                                         

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12 The Anglo-Saxon Chronicle Part 3: A.D. 920-1014 “Online Medieval and Classical Library Release #17.”

13This file was uploaded to Wikimedia Commons as part of a GLAM-Wiki partnership between the National Library of Poland and Wikimedia Polska. US work that is in the public domain in the US for an unspecified reason, but presumably because it was published in the US before 1929.

14Edward Thomas, "Shell Shock Recognized Before the Great War," Roads to the Great War, May 28, 2015. (accessed Sept. 2016). Oneiric relates to dreams or dreaming.

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1666 The Great London Fire

According to Stephen Bentley, the Great London Fire of 1666 produced many P.T.S.D.-like symptoms in the population. It was a devastating conflagration that killed many and permanently brought deep suffering to the people of London. John Evelyn’s Journal of the Great London Fire of 1666 records the following: 

"The conflagration was so universal, and the people so astonished, that from the beginning, I know not by what despondency or fate, but crying out and lamentation, running about like distracted creatures without at all attempting to save even their goods; such strange consternation there was among them.

This painting is a representation of the Great Fire of London, that lasted from September the second to September the sixth in 1666.15

Samuel Pepys personally described the fire in such terrible terms: “. . . and between churches and houses, as far as we could see up the hill of the City, in a most horrid malicious bloody flame, not like the fine flame of an ordinary fire.”. . . So great was our fear, . . . I . . . saw the saddest sight of desolation that I ever saw; everywhere great fires, oyle-cellars, and brimstone, and other things burning. I became afeard to stay there long, and therefore down again as fast as I could, the fire being spread as far as I could see it; . . . how horridly the sky looks, all on a fire in the night, was enough to put us out of our wits; and, indeed, it was extremely dreadful, for it looks just as if it was at us; and the whole heaven on fire. . . . and there saw it all on fire, . . . and the fire with extraordinary vehemence. . . . and such fear of fire in my heart, that I took little rest.”16

". . . and some principal Members of the City, notwithstanding which suspicion, the manner of the burning all along the Train, ans so blowen forwards in all its way by strong winds, make us conclude the whole was an effect of an unhappy chance, or to speak better, the heavy hand of God upon us, for our sins, shewing us the terror of his Judgment, in dust, raising the fire, and immediately after his miraculous, and never to be acknowledged Mercy, in putting a stop to it when we were in the last despair, and that all attempts for quenching it, however, industriously pursued seemed insufficient."17

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15Author of painting: Lieve Verschuier  (1627–1686), The Great Fire of London in 1666. The official position taken by the Wikimedia Foundation is that "faithful reproductions of two-dimensional public domain works of art are public domain". This photographic reproduction is therefore also considered to be in the public domain in the United States. In other jurisdictions, re-use of this content may be restricted; see Reuse of PD-Art photographs for details. US work that is in the public domain in the US for an unspecified reason, but presumably because it was published in the US before 1929.

16“Samuel Pepys Diary 1666 - Great Fire.” http://www.pepys.info/fire.html (accessed October 17, 2014).

17The London Gazette, From Monday, Septemb 3, to Monday, Septemb 10, 1666. "Whitehall, Sept. 8." This work is in the public domain in its country of origin and other countries and areas where the copyright term is the author's life plus 100 years or fewer. US work that is in the public domain in the US for an unspecified reason, but presumably because it was published in the US before 1929.

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1678 European Doctors

Stephen Bentley has done a massive amount of investigation on P.T.S.D. He tells us that as late as 1678, the Germans, French, and Spanish physicians had already identified the disorder we know today as P.T.S.D. They called it “nostalgia,” defining it by the empirical data, e.g., constant thinking of home, disturbed sleep or insomnia, weakness, loss of appetite, anxiety, cardiac palpitations, stupor, and fever. German doctors referred to P.T.S.D. as “Heimweh,” meaning “homesickness.” The French physicians, noting the same symptoms, called it “Maladie du pays,” and the Spanish termed it “estar roto,” or “to be broken.”

17th and 18th centuries: doctor, Josef Leopold Auenbrugger18 

In the 17th and 18th centuries, P.T.S.D., although not so named, was very much present during the never-ending wars once gunpowder became readily available. Authorities believed that homesickness among the young troops contributed to the effects observed by the physicians of the day. One such Austrian doctor, Josef Leopold Auenbrugger, noted P.T.S.D.-like symptoms in the closing days of the Seven Years' War.

In 1761, Austrian physician Josef Leopold Auenbrugger wrote about nostalgia in trauma-stricken soldiers in his book Inventum Novum. The soldiers, he reported, became listless and solitary, among other things, and efforts could do little to help them out of their torpor.19

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18Author and source unknown. US work that is in the public domain in the US for an unspecified reason, but presumably because it was published in the US before 1929. This work is in the public domain in its country of origin and other countries and areas where the copyright term is the author's life plus 70 years or fewer.

19A state of physical or mental inactivity; lethargy. "PTSD and Shell Shock,"History, History.com Editors, Updated: March 28, 2023.

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The French and Indian War (a.k.a., The Seven Years War, 1756-1763)

During the French and Indian War (a.k.a., The Seven Years War, 1756-1763), Stephen Bentley’s research suggests “the symptoms (of P.T.S.D.) were believed to be associated with soldiers’ longing to return home and unrelated to actual battlefield experience.” In his “A Short History of P.T.S.D,” Bentley noted, “The French surgeon Larrey described the disorder as having three different stages. The first concerns heightened excitement and imagination; the second a period of fever and prominent gastrointestinal symptoms; and the final stage is one of frustration and depression.”

The War of 1812

Gen. William Hull20

During the War of 1812, these mental traits were especially poignant in Gen. William Hull's life. George Washington had seen Hull’s promotion to General for bravery during the War of Independence just before the Northwest Army’s devastating defeat at the Battle of Detroit. The military tried and convicted Gen. Hull of cowardice, but President Madison commuted his sentence. Hull, the hero of Saratoga and Monmouth’s battles, probably suffered P.T.S.D. to a much higher degree than was reported until the battle of Detroit. Picture in the public domain.

Charles Dickens (1812 – 1870)

Charles Dickens (1812 – 1870) noted the symptoms he experienced after a train crash where ten people died, hurting as many as 49. He wrote, “I am curiously weak. . . I begin to feel it more in my head. . . but I write half a dozen notes, and turn faint and ‘‘sick’’. . . driving into Rochester yesterday I felt more shaken ‘‘than I have since the accident.’’21

On June 9, 1865, Dickens was present at the Staplehurst railway disaster. Ten passengers were killed and 40 were injured. 

Although some people have suggested Dickens' health deteriorated after this incident, the painful left foot and other symptoms pre-date the accident. Nevertheless Dickens did have post-traumatic flashbacks as his daughter Mamie recalls in her book:““My father suddenly clutched the arms of the railway carriage seat, while his face grew ashy pale, and great drops of perspiration stood upon his forehead, and though he tried hard to master the dread, it was so strong that we had to leave the train at the next station.””

“I cannot bear railway travelling yet. A perfect conviction, against the sense, that the carriage is down on one side (and generally that is the left, and not the side on which the carriage in the accident really went over) comes upon me with anything like speed, and is inexpressibly distressing.”22

After 1843, the overall trend in the annual suicide rate among active-duty personnel of the US Army increased. In 2 instances (i.e., 1866-1868 and 1875-1882), we were unable to differentiate suicide from other causes of death; therefore, we were unable to determine the suicide rates for these years. The suicide rate was highest in 1883, at 118.29 per 100, 000, from a force of nearly 23 000 service members.23

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20 Artist: James Sharples Sr. (1751-1811); Date: circa 1800. This work is in the public domain in its country of origin and other countries and areas where the copyright term is the author's life plus 100 years or fewer. US work that is in the public domain in the US for an unspecified reason, but presumably because it was published in the US before 1929. This photographic reproduction is therefore also considered to be in the public domain in the United States.

21 Description: English: Young Charles Dickens, c. 1830s, Date: 1905 (republication; original no later than 1836). Source: Emanuel Müller-Baden, "Bibliothek des allgemeinen und praktischen Wissens: zum Studium und Selbstunterricht in den hauptsächlichsten Wissenszweigen und Sprachen, Volume 5, 1905, Englische Literaturgeschichte, Seite 66, published by Bong in 1904, according to Google books. Scanned by User:Gabor. The original engraving was by Robert Seymour.

22 Mamie Dickens, My father as I recall him (London: Roxburghe Press, 1897), 112, in I.C. McManus, "Charles Dickens: a neglected diagnosis," The Lancet, Dec. 22, 2001. (accessed March 5, 2024)

23 Jeffrey Allen Smith, Michael Doidge, Ryan Hanoa; et al, "A Historical Examination of Military Records of US Army Suicide, 1819 to 2017," JAMA Network Open. 2019;2(12):e1917448.

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French neurologist Pierre Janet (1859–1947)24

The French neurologist Pierre Janet (1859–1947) was one of the first scientists to explore trauma’s psychological impact empirically. In a study of more than 5,000 patients, he suggested that traumatic memories have the ‘all or none’ feature. Janet recognized what he called ‘premeditation,’ when a person experienced a traumatic event and when the patient developed trauma-related symptoms. If the victim re-experienced a particularly traumatic event, Janet called this a dissociative flashback. Patients were incapable of processing the memories of a traumatic event.24

Janet argued that emotional shocks cause trauma because they prevent people who are not well-prepared from adapting successfully to specific situations. As a result, people experience feelings of fear, rage, sorrow, or  incompleteness.

Fixed ideas are distorted memories, experiences, imaginations, or appraisals of a traumatic event. A similar term is a rigid-thought complex, which describes what happens when an individual cannot change their views on or consider alternatives to a situation.25

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24 Pierre Janet Marie Felix. Photograph by Eug. Pirou. Source: https://wellcomeimages.org/indexplus/obf_images/c7/87/682dad72cf0482fa3c28678dad53.jpg Author: Wellcome Library, London; Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 http://creativecommons.org/licenses/by/4.0/. Onno van der Hart, Paul Brown and Bessel Van der Kolk. “Pierre Janet’s Treatment of Posttraumatic Stress.” Journal of Traumatic Stress 2, (1989). (accessed June 12, 2018)

25 Charlotte Nickerson, "Pierre Janet: French Neurologist and Psychologist," SimplyPsychology, October 9, 2023. (accessed Mar. 5, 2024).

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1884

German physician Hermann Oppenheim first coined the term “traumatic neurosis.” Oppenheim described 42 cases of “railway or workplace accidents.” Charcot would have none of it. He insisted that “these cases were only forms of hysteria, neurasthenia, or hystero-neurasthenia.” But after Charcot died, French psychiatry adopted the term “traumatic neurosis.”

The Belgian Jean Crocq reported 28 cases of railroad crashes, men and women who suffered from this neurosis. Symptoms included “dissociation caused by trauma, the pathogenic role of forgotten memories, and ‘cathartic’ treatment.”26

The Crimean War October 1853 - February 1856

During this war, “Irritable Heart” had been recorded, resulting in the incapacitation of soldiers. Doctors prescribed light duty and rest. “Many years after the end of the Crimean War, traumatized veterans are recognized as suffering from Da Costa syndrome or Effort syndrome, although neither name is used until long after the war.”27

The horrific suffering endured by the British troops in the Crimean War lacked the dignity and battlefield honor afforded by Lord Tennyson’s poetic stoicism in “The Charge of the Light Brigade.” For of the approximately 20,000 British troops that died in the East, in a vain attempt to settle the “Eastern Question” of what was to become of the Ottoman Empire, only 10 percent were killed in action. Although thousands of Germans, Swiss, and Italians fought for the British Army, most of the British military was composed of fellow compatriots. However, death was no respecter of persons as the vast majority of British military casualties unceremoniously and needlessly succumbed to a variety of factors afar from the battlefields.28

Crimean War 1854-56 Sergeant J. Brease, 11th Hussars, who participated in the Battle of Alma and the Charge of the Light Brigade at Balaklava. Portrait taken after he lost his arm while on picket duty at Inkermann and returned to England.29

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26 Hermann Oppenheim, Die Traumatischen Neurosen. 2nd ed. (Berlin, Germany: Hirschwald, 1892).

27 William Simpson - Crimean War - Huts and Warm Clothing for the Army.jpg "Print shows soldiers transporting winter clothing, lumber for huts, and other supplies through a snow-covered landscape, with partially buried dead horses along the roadside, to the British camps; huts under construction in the background." tinted lithograph, digitized from the original print. Simpson, William, 1823-1899, artist., Paul & Dominic Colnaghi & Co., publishers, Public domain.

28 Jeffrey Allen Smith, PhD, Kristi L. Masuhara, BA, B. Christopher Frueh, PhD, "Documented Suicides Within the British Army During the Crimean War 1854–1856," Military Medicine, Volume 179, Issue 7, (July 2014): 721–723.

29 This image is in the public domain because it is a mere mechanical scan or photocopy of a public domain original, or – from the available evidence – is so similar to such a scan or photocopy that no copyright protection can be expected to arise. The original itself is in the public domain for the following reason: This work created by the United Kingdom Government is in the public domain. This is because it is one of the following: It is a photograph taken prior to 1 June 1957; or It was published prior to 1974; or It is an artistic work other than a photograph or engraving (e.g. a painting) which was created prior to 1974.

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Suicide rates

Director-General Andrew Smith cataloged “suicides” as death by “disease.” Eighteen “diseased” soldiers officially took their own lives. “Attempting to calculate an accurate annual suicide rate per 100,000 is impossible because it is unclear how many of the 111,313 military personnel arrived in-country for the basic two years of the war, but the range is conservatively between 8 and 16 per 100,000, with the likely answer somewhere near the middle.” Interesting is the fact that of these 18 suicides, all but two suicides served in different regiments. Medical staff documented fifteen of the 18 suicides as “Died in General Hospitals and elsewhere (not in Regimental Hospitals) during the War.”30 

"While efforts to create a singular repository for tracking military suicide are relatively new, individual branches of the US military have tracked suicide among active-duty personnel with varying degrees of interest and analysis since the early 19th century. Although undertaken in an effort to identify causal links between health and climate to formulate “a system of medical geography,” the Statistical Report on the Sickness and Mortality in the Army of the United States used US Army “vital statistics of the troops extending over a period of twenty years”3 (ie, 1819-1839). In doing so, the statistical report explicitly recorded the first US Army suicides in the decade from 1829 to 1839. Unfortunately, the Surgeon General Office pooled the suicide data into multiyear date ranges associated with specific forts and barracks across the United States because the military was more concerned with associated data and geography than with investigating army wide trends."31

The American Civil War 1860 - 1865

During the Civil War, identifying the dead proved distressing to the men’s units and the family members waiting at home for some word from their relatives fighting in the war. In part, that was because of crude battlefield burials, if there were burials at all. The contempt each side eventually had for the other’s death was the cause. At Antietam, northern soldiers dumped 58 dead rebels into a well.

From 15% to 20% of the Union Army soldiers enlisted as volunteers between 9 and 17. "The average Union soldier was 25.8 years old."32 Ninety-three percent of the men would likely “experience mental and physical disease.” Soldiers and POWs alike fell victim to “cardiovascular disease, gastrointestinal symptoms, and would probably die “early.” Beyond the death and destruction of the war itself, many in the Union Army had relatives in the Rebel Army. “Family members” participated in trying to kill each other in close-quarter, hand-to-hand combat, with devastating consequences. This type of warfare caused tremendous distress not only because of the physical carnage but also because killing one’s kin at close range presented mental psychosis.

"Medics in the American Civil War were among the first to observe and treat the effects of industrialized warfare. Not yet labeled shell shock, traumatic neurosis was treated with the use of isolation, rest and relaxation, and the application of electricity. Given time, it was believed that the body would recharge itself and allow the mental state of the patient to return to normal. When time was not sufficient to cure a limp arm or leg, electricity would be applied to help recharge the area and restore feeling."33

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30 Jeffrey Allen Smith, Kristi L. Masuhara, B. Christopher Frueh. “Documented Suicides Within the British Army During the Crimean War 1854–1856.” Military Medicine 179, 7 (2014): 721–723. (accessed September 22, 2017).

31 Smith, et al., "A Historical Examination of Military Records of US Army Suicide, 1819 to 2017.

32 Civil War Facts, "Q. What was the average soldier's age?" Updated November 16, 2023. (accessed Mar. 5, 2024).

33 "Before the First World War," Restoring Perspective. https://www.lib.uwo.ca/archives/virtualexhibits/londonasylum/beforewwi.html

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Suicide Rates During and After the Civil War

Hadley-Cousins gives some rather disturbing statistics from an official report by “The Medical and Surgical History of the War of the Rebellion.” Military authorities discharged eight hundred fifty-three soldiers for insanity, 1% of the total post-war discharges. That number is probably relatively low, considering the number of battles, the casualties, and the types of wounds sustained from five years of war. We are only made aware of the mental instabilities from the remaining asylum records. For men like Daniel Folsom, who believed he“still had a chance,” and “I shall try and be a man,” as he wrote home later, reenlisting in the army helped “to reaffirm his manhood through battle.” Folsom survived the war as a 1st Lieutenant with a New York regiment, living to marry and produce six daughters. "This cross-sectional study, which includes data on all active-duty personnel in the US Army from 1819 to 2017, documented trends in suicide rates."34

Wallace Woodford - Once back in the safety of his bed, “Wallace Woodford flailed in his sleep, dreaming that he was still searching for food at Andersonville. He perished at age 22, and his family buried him beneath a headstone that reads: ‘8 months a sufferer in Rebel prison; He came home to die.’”35

Those soldiers diagnosed as “insane” from the exposure and rigors of battle would often wander about the countryside. Some died utterly unaware of the new dangers they faced. Many of these once brave but later broken men existed for years after the war and eventually committed suicide. Others spent their final days in insane asylums. Soldiers’ homes sprang up throughout the nation after the war, their need growing with the ensuing years rather than decreasing.

Dr. Jacob Mendez Da Costa - Following the U.S. Civil War, doctors began to notice an increase in troops’ heart problems, attributed to fatigue from war conditions. Doctors treated fatigue, anxiety, high blood pressure, and irritable heart conditions with rest. In 1871, Dr. Jacob Mendez Da Costa converted the term “nostalgia” to “soldier's heart” after he began to notice an increase in heart problems among soldiers, as well as among civilians. He attributed the symptoms to fatigue caused by excessive marching, complex service in the field, and missing loved ones. The recommended treatment for soldiers' heart also consisted of rest. “Instances of sudden paralysis or loss of sensation were identified as traumatic hysterical neurosis.”36

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34 Jeffrey Allen Smith, Michael Doidge, Ryan Hanoa; et al, "A Historical Examination of Military Records of US Army Suicide, 1819 to 2017," JAMA Network Open. 2019;2(12):e1917448. (accessed Mar. 5, 2024). "Starting in 1843, the overall trend in annual suicide rates among active-duty service members in the US Army increased, with a peak rate of 118.3 per 100 000 in 1883. . . . we found that data gathered by the US military during the US Civil War provided a conservative estimated suicide rate of between 8.74 and 14.54 per 100 000 among white individuals who belonged to the active-duty Union Army. . . . Specifically, 19th-century data came from US Army Surgeon General annual and periodic statistical reports,3-5 and the Medical and Surgical History of the War of Rebellion, 1861-1865." Ibid.

35 John Banks, "Avon's Wallace Woodford 'came home to die'," John Banks Civil War Blog, October 22, 2011. https://john-banks.blogspot.com/2011/10/avons-wallace-woodford-came-home-to-die.html.

36 Thomas Eakins. Public domain. Sketch for Portrait of Dr. Jacob Mendez da Costa.png. O Paul, "Da Costa's syndrome or neurocirculatory asthenia," British Heart Journal 58 (4)(Oct. 1987): 306-315; Cf. Wooley, "Jacob Mendez DaCosta: medical teacher, clinician, and clinical investigator," American Journal of Cardiology 50 (5) (November 1982): 1145-48.

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Florence Nightingale (1820–1910) 

Florence Nightingale was a remarkable and religious woman, born into an aristocratic British family. Her parents educated her at home. Although frail, Florence was exceptionally independent and thoughtful. She grew into womanhood when British women had few rights, and the society passed over females of insight and intellect like Florence.

Her memories of nursing wounded and dying men during the Crimean War. She was a “bereaved, haunted woman” who walked her room during the night, unable to sleep. It was not until her sixties that her troubles began to subside. She had become a “cold, obsessed, and tyrannical workaholic.” Her more positive transformation came late in life, albeit gradually. The mental hardness produced by her medical activities during the Crimean War had softened, and Florence showed hopeful signs of life. She even began pursuing more normal relations with old friends. After attending to her last patient, Florences’s experiences in Scutari had long since eroded the nursing desire. Miss Nightingale died of “old age and heart failure” at age 90.37

Treatment: The Russo-Japanese War (1904-1906)

"During the Russo-Japanese War (1904–1905), the first detailed description of “war neurosis” emerged with the first use of psychiatric specialists by the Russians.38

". . . Russian attempts to diagnose and treat battle shock represent the birth of military psychiatry. The Russians’ major contribution was their recognition of the principle of proximity, or forward treatment. Although it’s believed by most armies today that the Russians were right in treating psychiatric casualties close to the front, with the goal of returning them to the fight, the recorded rate of those who returned to battle suggests the method was not very successful. In actuality, less than 20 percent were able to return to the front."39

Russian psychiatrists  

The most notable Russian psychiatrist was Avtocratov, who first developed what came to be known as “forward psychiatric treatment.” Russian doctors and military command first noticed Post-battle neurosis. Avtocratov ran a 50-bed hospital for treating psychiatric patients at Harbin, Manchuria. The uncompleted Trans-Siberian Railway moved psychiatric patients with great difficulty over rugged terrain and long distances, creating the need for close-to-the-front treatment. In 1904, doctors treated some 1,500 patients. 1905, that number increased to 2000, precipitating calling in Russia’s Red Cross Society. A German doctor, Honigman, served in this body. It was Honigman who labeled traumatic patients with “war neurosis” [Kriegsneurose] in 1907. Previously, psychosis was called “combat hysteria” and “combat neurasthenia.” Honigman also noticed a similarity between Russian war survivors and Oppenheim’s reported railway crashes.40

A staff officer's scrap!book during the Russo-Japanese war (1906) (14781110912).jpg41

m Ashigu towards Shohokka, and then turned due east, crossing the Hunho opposite Kojiho, which he attacked. There Mistchenko was met by the Eighth Division and by part of the SecondDivision ; and by 6.30 p.m. on the 27th the Russian cavalry was driven back, one party moving due north towards Heikoutai. There was bayonet work in Somaho this day. During the night of the 27-28th, the Eighth Division attacked and took the line Laokyo-Somaho. Meanwhile the Russians had been expelled from Liujoko by the Fifth Division. At Gokashi, two * A regimental officer said to me, I can tell you though, it was not only the Second Division who  were clever. The Cavalry Brigade were pretty sharp, too, I can tell you. When their eight squadrons were opposed by twenty Russian squadrons, they formed small columns, which advanced, pretending to be the guns of batteries,Each little column dug a little gun-pit, and so the stupid oldRussians spent four hours firing shell at what they thought was our splendid horse artillery.

Text Appearing After Image:

Fuji Veils Her Face 357 and a half miles south-west of Heikaotai, the SecondDivision had driven out the enemy after heavy fighting.But at Heikoutai the Russians fought like heroes.The Eighth Division made some fine attacks upon them on the 28th, but were each time repulsed, mainly by the fire of the Russian machine guns.Had our Division been less reliable than the Eighth, which, as you know, is recruited from the north-east of Japan, perhaps the affair might not have ended quite so well for us.* Curiously, the Kobi Brigade, attached to the Eighth Division, were also from the North-east, so the Russians at Heikoutai were in bad luck. Tatsumi gave orders for a final attack at day-light on the 29th, but during the night Okamis' Brigade advanced from Somaho on Heikoutai, on its own initiative, and was repulsed badly. The otherBrigade attacked as ordered at 5.30 a.m. and found the Russians in the act of retiring!

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37 Elizabeth Fee and Mary E. Garofalo, “Florence Nightingale and the Crimean War.” American  Journal of Public 101, (5) (May 2011). (accessed January 9, 2018).

38 H. Thakur, "Posttraumatic stress disorder: Learning the lessons of the past." Federal Practitioner 25, 10 (2008):31-35, in "Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and Their Families," Institute of Medicine (US) Committee on the Initial Assessment of Readjustment Needs of Military Personnel, Veterans, and Their Families. Washington (DC): National Academies Press (US); 2010. Paintings of Russo-Japanese War by Nikolai Samokish, Battle of Telissu. The author died in 1944, so this work is in the public domain in its country of origin and other countries and areas where the copyright term is the author's life plus 75 years or fewer. This work is in the public domain in the United States because it was published (or registered with the U.S. Copyright Office) before January 1, 1929.

39 Bentley, A Short History of PTSD. "Unfortunately the mental health of soldiers in the late 19th century and early 20th century was largely ignored through the Boer War, the Russo-Japanese War, and the Balkans War. As such, the treatment of traumatic neurosis was not further developed." "Before the First World War," Restoring Perspective.

40 Marc-Antoine Crocq, "From shell shock and war neurosis to posttraumatic stress disorder: a history of psychotraumatology," Dialogues Clinical Neuroscience 2 (March 2000): 47–55.

41 Authors: Hamilton, Ian, Sir, 1853-1947. Subjects: Russo-Japanese War, 1904-1905. Publisher: London : Edward Arnold. Contributing Library: University of California Libraries. 

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Shell Shock

During World War I and World War II, psychological trauma was termed “shell shock” and considered to be the result of mortar rounds and artillery shells that continuously bombarded the troops. This phrase became the standard reference to traumatized troops. It was coined by Myers, a British military psychiatrist, in 1915.

German shell bursting close to our trenches (4687968293).jpg

Shelling near the British trenches, Western Front, during World War I. This photograph must have been taken by one of the official war photographers as it appears to have been shot from inside a frontline trench. It shows two great plumes of earth and stones erupting not far in front of the trench, as a result of German shelling. The constant danger and noise of the shelling caused many men to suffer from shell-shock, as well as more obvious and easily treated injuries. The name Alfieri in the corner of the print refers to the Alfieri Picture Service, Fleet Street, London, which appears to have been a Press picture distributor.[Original reads: 'German shell bursting close to our trenches.']

Mott wrote a year after the Armistice, describing neurosis, hysteria, and neurasthenia as physical shock and horrifying conditions that could cause fear, which in turn produced an intense effect on the mind. Hysterical symptoms included paralysis, contractions, disordered gait, tremors, and shaking. Neurasthenia symptoms include lassitude (mental weariness), fatigue, exhaustion, headaches, and particularly vivid and terrifying dreams with startle reflexes. 

Probably over 250,000 men suffered from ‘shell shock’ as result of the First World War. The term was coined in 1915 by medical officer Charles Myers. At the time it was believed to result from a physical injury to the nervous system during a heavy bombardment or shell attack, later it became evident that men who had not been exposed directly to such fire were just as traumatised. This was a new illness that had never been seen before on this scale. The condition was poorly understood medically and psychologically. Take a look at the War Committee Report (WO 32/4748) on the condition to find out more about attitudes towards it just after the war. Today, the condition is known as post-traumatic stress disorder and the treatment and attitude to it are very different.42

Shellshock2 (cropped).jpg. Image from The Great War taken in an Australian Advanced Dressing Station near Ypres in 1917. The wounded soldier in the lower left of the photo has a dazed, thousand-yard stare - a frequent symptom of "shell-shock". Photograph taken by Official War Photographer at an Australian Advanced Dressing Station near Ypres in 1917. The wounded soldier in the lower left of the photograph has the "thousand yard stare" indicative of shell-shock.

Given that this photo was taken 100 years ago by an employee of the British Government, I believe that copyright has expired and it is now in the public domain. Public domain. Shellshock2 (cropped).jpg Copy. 1917

Neurasthenia

[[File:Medical Department - Hospitals - In Theater of Operations - France - American Soldiers Recovering from War Neurosis in a Rest Camp Established in the Forest of Chateau Chambord, Captain Denis, American Red Cross - NARA - 45497016.jpg| Medical_Department_-_Hospitals_-_In_Theater_of_Operations_-_France_-_American_Soldiers_Recovering_from_War_Neurosis_in_a_Rest_Camp_Established_in_the_Forest_of_Chateau_Chambord,_Captain_Denis,_American_Red_Cross_-_NARA_-_45497016]] Copy. 1917. Scope and content: Date Taken: 10/1/1918. Photographer: American Red Cross, France. Unknown author or not provided. Public domain.

Two cases of neurasthenia which also give details of trench warfare and other injuries. The symptoms of this condition include physical and mental exhaustion with headaches or irritability and can be linked to depression or emotional stress. Many ‘shell shock’ cases displayed symptoms of neurasthenia. (Catalogue ref: MH106/2101)

Neurasthenia is an ill-defined medical condition characterized by lassitude (mental weariness), fatigue, headache, and irritability, associated chiefly with emotional disturbance. In 1914, thirty-two-year-old Cpl. A. Xxxxxxxxxxx had served sixteen years in the British military. Xxxxxxxxxxx served with the First Cheshires when he suffered a traumatic injury in France. Captain B. McFarland recorded the following about Cpl. Xxxxxxxx on September 12, 191. at 4th Northern General Hospital, Lincoln: 

He has only four front teeth-top side two molars, bottom side and he could not eat biscuits.

On the 7th last month he was out scouting at 7.30 he got 1½ miles into enemies’ lines by mistake he was on a bicycle & had orders to retire- when ½ way back Germans opened fire on either side of road- this corporal was last man. They put a log in front of bicycle & threw him head over heels into a German trench & two of them took him prisoner to their quarters. At 2.30 their [position] was blown for an attack & the 2 … left him & whilst they were away, through a hole in the hedge behind his trench he scrambled to a barn & then jumping into German trench & ran up it for 100 yards until he saw the telegraph lines of British troops. He then ran across the road, jumped into a trench 2 feet deep and then there were about 50 shots fired at him, then he saw the Bedfords Regiment & reported position of enemy to them. He has been subject to Neurasthenia ever since. He was sent to 14 General Hospital for 4 days & then sent on here.

He is much better, sleeps well & eats well & no pains. He will be fit for furlough in a few days.43 

German psychiatrist Robert Gaupp reported in 1917:

The big artillery battles of December 1914... filled our hospitals with a large number of unscathed soldiers and officers presenting with mental disturbances. From then on, that number grew at a constantly increasing rate. At first, these soldiers were hospitalized with the others ... but soon we had to open special psychiatric hospitals for them. Now, psychiatric patients make up by far the largest category in our armed forces ...The main causes are the fright and anxiety brought about by the explosion of enemy shells and mines, and seeing maimed or dead comrades ...The resulting symptoms are states of sudden muteness, deafness ... general tremor, inability to stand or walk, episodes of loss of consciousness, and convulsions.44

French psychiatrist Régis reviewed 88 cases of mental disorder in 1915. They discovered that “20% only presented with a physical wound, but in all cases, fright, emotional shock, and seeing maimed comrades had been a major factor.”45

Medical Department - Hospitals - In Theater of Operations - France - One of the Cures Effected by the Treatment of War Neurosis, the Condition that Used to be Described as Shell Shock - NARA - 45497008.jpg46

During the First World War, British Generals executed 306 soldiers for cowardice. “Herbert Morrison. . . was the youngest soldier in the West India Regiment when he was led in front of the firing squad and gunned down for desertion. A ‘coward’ at just 17. . . . To this day, the Ministry of Defence refuses to give a pardon to the 306, convicted of cowardice, though even in 1914, people knew all about ‘shell shock’ - what the modern world calls Post Traumatic Stress Disorder. . . . The historic shaming of men - and, consequentially, their women and children - happened in other countries too. In France and Germany, cowardice and desertion led to the same outcome as in England: a firing squad. But in the case of Germany, only 25, not 306, died as a result of cowardice. And in both countries, that shame was lifted within a decade of the war's end when belligerent countries built official memorials. “Only in Britain do we continue to dishonor the victims of shell shock. The Government’s argument echoes the one first set out by John Major. He told the Commons that pardoning the ‘deserters’ would be an insult to those who died honourably on the battlefield and that everyone was tried fairly.”47

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42 War office report on ‘Shell shock.’ The National Archives. (accessed Mar. 21, 2022).

43 Neurasthenia cases (b), The National Archives. (accessed Mar. 5, 2024).

44 B. Ulrich, B. Ziemann, Frontalltag im Ersten Weltkrieg. Wahn und Wirklichkeit (Frankfurt, Germany: Fischer, 1994),102–103.

45 Crocq, "From shell shock and war neurosis to posttraumatic stress disorder."

46 Scope and content: Original Caption: One of the Cures Effected by the Treatment of War Neurosis, the Condition that Used to be Described as Shell Shock. Captain Denis, American Red Cross, by taking these patients away from noise and congestion of a hospital to a quiet out of door life in the Forest at Chateau Chambord near Blois, France. Date Taken: 10/1/1918. Photographer: American Red Cross, France. Unknown author or not provided. Public domain

47 John Sweeney, “Lest we forget: the 306 'cowards' we executed in the first world war.” The Guardian, November 13, 1999. https://www.theguardian.com/world/1999/nov/14/firstworldwar.uk (accessed January 27, 2022).

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Suicide Rates During and After WWI

The worst figures regarding WW I suicide rates happened in the years following the Great War. The causes were due to what we now know as “P.T.S.D.” Unfortunately, the suicide of combat veterans years after their service is still all too common today. One can only imagine how bad it was in W.W.I. Combat trauma had various labels then. It was known as “Shell Shock,” “Combat Stress,” or “War Neurosis.” Combatants diagnosed as such were typically labeled “cowards” or believed to be “lacking in moral fiber.” 

Charles Campbell, who was introduced at the outset of this piece, was 23 years old when he ended his life. He returned from overseas in late 1918 and shot himself in January the following year. His leg had been badly shattered by shellfire and, the Globe concluded, he was “evidently morose as the prospect of extended treatment.”48

By war’s end some continued to view shell-shocked men as suffering from trauma to the nervous system, but, as the reporting on Private George Smith’s suicide in Winnipeg attests, newspapers also attributed suicide to mental health issues. In Smith’s case, depression caused by shell-shock led to his suicide.49

Economic difficulties also caused suicide. William Dowler, formerly a Captain in the Canadian Medical Corps, committed suicide in November 1919 after finding himself in “straitened circumstances.” According to the Star, his pride was such that he had refused monetary assistance.50

The “lucky” were discharged and sent home untreated. Authorities hospitalized a minority of the “cowards.” The military made examples of the “unlucky” soldiers and gave them a “field court-martial.” The trial resembled a “Mock Trial” or “Kangaroo Court.” Found guilty and sentenced to death, their comrades shot them. “Knowing they would face such action, and the disgrace associated with such issues, suicide amongst front line soldiers soared.”51

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48 “Sad Case of Suicide, Clearly Premeditated,” Globe, 21 January 1919, p. 2.

49 “Commit Suicide, Two Veterans Take their Lives over the Weekend,” Toronto Daily Star, 14 July 1919, p. 20.

50 “Canadian Capt. Suicides,” Toronto Daily Star, 24 November 1919, p. 20.

51 Sweeney, “Lest we forget."

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Gallipoli 52

May 4th, 1915

Dear Meta,

". . . We rushed straight to the top and turned 2,000 Turks off the redoubt and poured lead into them at about ten yards’ range. Nearly all the officers had been killed or wounded by now.

"A Colonel Doughty-Wylie led the attack and was killed at my side. I wrote in about him to the staff, and he was awarded the VC. I buried him that evening and got our padre to read the service over him. It was 6pm by the time we finished firing on the Turks, and we dug ourselves in in an outpost position."53

Future British Major Guy Nightingale would survive the horrors of the Gallipoli campaign without a scratch. After the Gallipoli disaster, the British military transferred its unit to the Western Front in France. He left the service in 1926 and retired to Somerset but struggled to adjust to civilian life. He died by suicide in April 1935, the 30th anniversary of his landing at Gallipoli, having suffered from alcoholism and depression.

On April 18th, 1935, in the peaceful English village of Wedmore, in Somerset, at the quaint address of Thatch Cottage, Guy Nightingale died within a week of the 20th anniversary of his landing on V Beach. Three causes of death were listed on his death certificate: cardiac syncope, delirium tremens and chronic alcoholism. Some said Nightingale died by his own hand; a doctor now might simply attribute the ending of his life to post-traumatic stress disorder.54

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52 Artist: Charles Dixon (1872-1934). New Zealand troops were part of the Allied invasion force that landed at what soon became known as Anzac Cove. This file is licensed under the Creative Commons Attribution-Share Alike 2.0 Generic license.

53 Robert Yeoman, "Letters from Gallipoli," The Irish Times, Apr. 25 2015. (accessed Mar. 5, 2024).

54 Yeoman, "Letters from Gallipoli."

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World War II (1939-1945)

World War II was the most destructive conflict in history. It cost more money, damaged more property, killed more people, and caused more far-reaching changes than any other war in history. 

"In past wars and in the opening days of World War II, the War Department believed that  soldiers suffering from combat fatigue had an underlying, pre-existing mental condition.

"Accordingly, inductees were psychologically screened and rejected for service if they were perceived to possess a weak constitution or mental deficiencies that were considered potential indicators of a breakdown in combat. However, after the Guadalcanal Campaign, the US military learned that a serviceman’s ability to survive the psychological rigors of combat could not be predicted. The point was driven home when in 1943, one of the nation’s elite fighting forces suffered significant psychiatric casualties. More than 500 marines returning from Guadalcanal were treated for symptoms such as tremors, sensitivity to loud noises, and periods of amnesia—the condition was termed 'Guadalcanal Disorder.'”

"As more American servicemen entered into combat, the number of psychological casualties steadily rose. During the Normandy Campaign, army psychologists noted that the combat effectiveness of troops sharply declined after 30 days of combat. After 45 days, troops were in a near vegetative state. Psychiatrist John Appel, who studied combat exhaustion cases during the Battle of Monte Cassino and Anzio Campaign, came to the sobering conclusion that, 'Practically all men in rifle battalions who are not otherwise disabled ultimately became psychiatric casualties.'”55

As the events of World War II unfolded, psycho-analytic concepts underwent modifications; physicians used multiple analytic theories to interpret war-related neurosis. These theoretical concepts represented an attempt to explain the various symptoms seen in war neurosis in terms of an intrapsychic model, which downplayed the role of the trauma itself.

"Of the 800,000 American soldiers who fought the Germans in WWII, 37.5% were diagnosed as severe psychiatric cases and thus discharged. Five hundred four thousand Army veterans “were lost to the fight for psychiatric reasons. Another 1,393,000 suffered symptoms serious enough to debilitate them for some period.”56

Psychiatric studies conducted in Canada, America, and Britain during the Great War observed the following in their soldiers: “acute exhaustion, war fatigue, war neurosis, and old soldier’s syndrome.” In 1945, Saul formulated combat fatigue and fight-or-flight, which became common parlance in psychology.

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54 Alex Dan, “World War II Statistics.” April 2, 2015. http://www.statisticbrain.com/world-war-ii-statistics/.http://en.wikipedia.org/wiki/World_War_II_casualties, (accessed November 6, 2014).

55 "World War II Post Traumatic Stress," The National WW II Museum, June 27, 2020. https://www.nationalww2museum.org/war/articles/wwii-post-traumatic-stress.

56 Bentley, "A Short History of PTSD."

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Suicide Rates During and After WWII

In California, reports have surfaced that some of the “Greatest Generation” (WW II veterans) have decided to conclude their lives by suicide. This decision is “roughly double the rate of veterans under 35, those who are returning home from Iraq and Afghanistan,” Aaron Glantz wrote four years ago. Glantz discovered that 532 veterans living in California, all over 80 years old, had killed themselves between 2005 and 2008. Glantz interviewed 86-year-old Ken Norwood for his piece. German artillery shot Norwood's bomber down over Belgium while on a bombing raid in a B-24. He awoke in a German field hospital because the impact of the crash threw him out of the bomber. That began his cattle car adventure across Europe at the behest of the Third Reich. He says that he was kept underground and alone in a cell. His toilet was a trench. Mr. Glantz said he’s gotten used to the flashbacks that play in his head like a DVD. As he ages, however, the flashbacks have gotten worse. “I have fewer activities in daily life now. I don’t have a professional career to pursue or a family to come home to,” he stated. “My kids are grown. They have their own lives.”57

"The US Army did not systemically concern itself with suicide rates during the 1950s and early 1960s; the publication of suicide data in Surgeon General Office annual reports became sparse following the reorganization of the US Army beginning in 1962, which significantly reduced the Adjutant General’s authority, including their publication and records management functions. For the 1960s and 1970s, this study study primarily relied on the work of US Army health analysts, clinical researchers, and epidemiologists, whose peer-reviewed research made Surgeon General Office data public."58

Treatment 

In World War II, authorities attempted to avoid the horrific casualty levels seen in World War I. They administered psychological screening tests to eliminate those who could not tolerate battle. The tests concluded in failure, and there were very few rejected recruits. Soldiers who suffered from shell shock in World War II needed continual “forward treatment.”59

"Treatments in this war differed greatly from those of the First World War. Instead of the use of electricity, soldiers were treated with much more care and compassion. There was an emphasis placed on fully treating a patient, rather than simply making a soldier well enough to fight again. Soldiers could generally expect simple talk and drug therapies.

"The terminology of war-related mental illness also changed. "Shell shock" was no longer the preferred term. Instead, soldiers suffered from combat or battle exhaustion. The simplest therapy was rest, sometimes combined with tranquillizers. Other treatments included the use of electroshock therapy, hypnosis, and narcotherapy. This last treatment option involved the use of Pentothal, a 'truth serum.' Under the influence of this drug, a soldier would recount their traumatic experience, but afterwards be unaware of their retelling. A psychiatrist would later work with the un-medicated individual, and guide their questions to bring about a more successful recovery."60

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57 Aaron Glantz, "Investigation: Suicide Rates Soaring Among WWII Vets," New America Media,  November 11, 2010. (accessed Mar. 5, 2024).

58 W.E. Datel, A.W. Johnson Jr., "Suicide in United States Army personnel, 1975-1976." Military Medicine 144(4) (1979):239-244.  W.E. Datel, "The reliability of mortality count and suicide count in the United States Army." Military Medicine 144(8) (1979):509-512, in "A Historical Examination of Military Records of US Army Suicide, 1819 to 2017." JAMA Network Open.

59 Rene Wolf, "Insight into the History of Treatment for Post Traumatic Stress Disorder," Edited by Daniel P. McGolldrick. September 10, 2010.

60 "The Second World War," Restoring Perspective, https://www.lib.uwo.ca/archives/virtualexhibits/londonasylum/wwii.html#:~:text=Instead%2C%20soldiers%20suffered%20from%20combat,Pentothal%2C%20a%20'truth%20serum.  

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The Korean War (1950-1953)

The British Journal of Psychiatry surveyed Australian Korean War veterans fifty years after the war. Below are some of their findings: 

"Within the veteran’s group, increasing odds of meeting criteria for P.T.S.D. or depression were both associated with increasing combat exposure, decreasing level of rank, increasing the duration of deployment, being first deployed before the armistice, and being wounded in action. There was also an association between both psychological health outcomes and Service branch, with Army veterans demonstrating the greatest odds of P.T.S.D. or depression, followed by Navy veterans, and with Air Force veterans demonstrating the lowest odds. The association between P.T.S.D. and increasing level of reported combat exposure was particularly strong, with veterans who reported heavy combat almost 15 times more likely to meet criteria for P.T.S.D. than veterans who reported no combat. The dose-response slope indicates that the expected increase in the odds of P.T.S.D. per categorical increase in combat exposure level (e.g. from moderate to moderate-heavy) is 65%. The association between depression and combat exposure was also strong, with a 37% expected increase in the odds of depression per categorical increase in combat exposure level. 

Marines are crouched and ready to move out again as enemy fire slackens.

Sergeant John Babyak, Jr., U.S. Marines (Official Marine Corps Photo # A6630)(http://www.tecom.usmc.mil/HD/images/KWC/Combat_photos/East/A-6630.JPG)

Public domain. U.S. Marines in the Korean War 001.jpg

"The other most notable association was with rank; with enlisted ranks being four times more likely – and non-commissioned officers three times more likely – than officers to meet criteria for P.T.S.D. Enlisted ranks and non-commissioned officers were also more than twice as likely as officers to meet the criteria for depression. The dose-response slopes indicate a 54% increase in the odds of P.T.S.D. and a 43% increase in the odds of depression per categorical decrease in rank."61 

Ikin, Creamer, Sim, and McKenzie did a similar study entitled, “Comorbidity of P.T.S.D. and depression in Korean War veterans: prevalence, predictors, and impairment,” they discovered, “Rates of P.T.S.D. and depression are high in Korean War veterans. However, the prevalence and impact of the two disorders occurring comorbidly has not been investigated. This paper aims to investigate the extent to which P.T.S.D. and depression co-occur in Australian veterans of the Korean War, the symptom severity characteristics of comorbidity, the impact on life satisfaction and quality, and the association with war-related predictors.”62 (emphasis added)

Suicide Rates During and After the Korean War 

As reported by historians, 54,246 service personnel were KIA during the war in Korea, 1950-53. However, on June 6, 1993, the Department of Defense revised those numbers. The official count now includes all active-duty members who died for any reason, not merely combat. The altered reporting hoped to “raise the issue in the national consciousness” and “clarify the numbers,” according to a Pentagon spokesman, Rear Adm. Craig Quigley, in 1993. As it currently stands, the division of battle deaths for three years of conflict, 1950-1953, has officially been set at 33,686 KIAs and 2,830 non-battle deaths. This number leaves 17,730 military personnel who died in Korea as “other deaths.”63 

Infantry troops about to board U.S. Army Sikorsky H-19 Chickasaw helicopters to be transported to the front lines at the 6th Transportation Helicopter Company, Eighth Army, Korea. Camera Operator: PFC E. E. Green, U.S. Army. Public domain. Korean War HA-SN-98-07085.JPEG Copy. [[File:Korean War HA-SN-98-07085.JPEG|Korean_War_HA-SN-98-07085]]Copy. April 15, 1953.

Specifically, although precise estimates of the prevalence of PTSD among Korean War combat veterans have varied depending on sampling and method, studies from the 1990s and early 2000s suggested that the prevalence of PTSD and other mental health concerns as well as the severity of symptoms, suicide risk, and psychosocial adjustment difficulties were worse among Korean War combat veterans relative to those among World War II combat veterans; however, both groups had lower prevalence than did Vietnam War combat veterans.64

Treatment 

Medical professionals discontinued the forward treatment of psychological cases and removed them from the front lines. Instead, “rest and relaxation” (R&R) replaced forward treatment. The general medical consensus was a frequent rotation of troops. However, Colonel Albert J. Glass fought to have the hard-won principles of “forward treatment” reimplemented in previous wars. The newest approaches to psychological treatment discovered that approximately 90% of the troops suffering psychological distress resulted after returning to the front lines. 

On the Korean War Educator website, researcher Jim Goodwin stated, “During the Korean War, the approach to combat stress became even more pragmatic. Due to Albert Glass’s work, each breakdown found doctors treating patients in a situational manner. Clinicians once again provided immediate onsite treatment to affected individuals, always expecting that the combatant would return to duty as soon as possible. The results were gratifying. During World War II, 23 percent of the evacuations were for psychiatric reasons. But in Korea, psychiatric evacuations dropped to only six percent. It finally became clear that the combatant’s situational stresses were the primary factors leading to psychological casualty.”

During the Korean War, the APA Committee on Nomenclature and Statistics published the first Diagnostic and Statistical Manual of Mental Disorders (DSM). After World War II, military psychiatrists interpreted and then described “combat stress” characteristics. By defining the ‘reactions’ portion of “gross stress reactions,” these psychiatrists sparked the future road for proper treatment for veterans and civilians.65 

______________

61 Jillian F. Ikin, et al, "Anxiety, post-traumatic stress disorder and depression in Korean War veterans 50 years after the war," The British Journal of Psychiatry, January 02, 2018. (accessed Mar. 5, 2024).

62 Ibid.

63 “Data on Veterans of the Korean War.” Department of Veterans Affairs, June 2000. (accessed: August 8, 2013). “Facts About the Korean War.” (accessed November 6, 2014).

64 Barton W. Palmer, PhD, Samantha Friend, MD, Steve Huege, MD, Mallory Mulvaney, BA, Albaraa Badawood, MD, Abdulaziz Almaghraby, MD, and James B. Lohr, "Aging and Trauma: Post Traumatic Stress Disorder Among Korean War Veterans," Federal Practitioner. 36, 12 (Dec. 2019): 554–562.

65 Jim Goodwin, “The Etiology of Combat-Related Post-Traumatic Stress Disorders.” Korean War Educator (accessed November 4, 2014). "Combat stress teams continued to develop throughout the Korean War, in which a clinical psychologist, a social worker and about six enlisted specialists were added to the division psychiatrist to form the Division Mental Health Section. Also, Korea saw the first autonomous, mobile psychiatric detachments." CPT Bret A. Moore, Psy.D. & CPT Greg Reger, Ph.D., "Historical and Contemporary Perspectives of Combat Stress and the Army Combat Stress Control Team." (accessed Mar. 5, 2024).

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The Vietnam War (1964-1975)

The Journal of Psychiatric and Mental Health Nursing provides this observation: “Perhaps one of the most striking features of this case is that it concerns a very ordinary man living in a very ordinary street in a very ordinary catchment area. This does beg the question of how many other veterans of armed conflict suffer in silence from P.T.S.D. symptoms.” The next U. S. war, Vietnam, was a post-Korean War. Once again, the Vietnam Veterans had to fight the V.A. to have combat trauma recognized as a symptom of combat.

U.S. Army Bell UH-1D helicopters airlift members of the 2nd Battalion, 14th Infantry Regiment from the Filhol Rubber Plantation area to a new staging area, during Operation "Wahiawa", a search and destroy mission conducted by the 25th Infantry Division, northeast of Cu Chi, South Vietnam, 1966.

James K. F. Dung, SFC, Photographer. Public domain. UH-1D helicopters in Vietnam 1966.jpg Copy. [[File:UH-1D helicopters in Vietnam 1966.jpg|UH-1D_helicopters_in_Vietnam_1966]]Copy. May 16, 1966

The term Post Vietnam Syndrome was used to describe returning soldiers with trauma symptoms. This syndrome usually consists of combat-related nightmares, anxiety, anger, depression, alcohol and/ or drug dependence, and poor responsiveness. The term post-traumatic stress disorder was not used in the DSM until the DSM-III was published in 1980 under anxiety disorders. Before that this condition was viewed as stress response syndrome, which was a type of gross stress reaction. The policy for receiving treatment and compensation for P.T.S.D. for soldiers in the military during the war was that if the soldier experienced symptoms 6 months after their return home it was considered a “transient situational disorder.” This meant that it was a pre-existing condition that was not eligible for treatment by the United States Government. Even though the soldiers who were victims of P.T.S.D. did not receive compensation from the government. P.T.S.D. as a clinical diagnosis was evolving into a more complex and real disorder. This policy is unsettling to hear because P.T.S.D. can occur anytime after returning home from war and many cases occur with delayed onset, this is referred to as chronic rather than acute which is immediate.

Gannon: "You go to Vietnam your ear you're actually a human being. "You fight for year and you spent a year in a bush. "You literally turn into an animal. You literally don't realize how much you change, until you come back. I come back, I hear car noises, I hear horns. Your nerves are shot. You're not sure what's gonna happen, and you were scared to death of everything. You hear about Vietnam, so I want to make sure my back is covered.

Colonel Hoisington visits with members of the WAC Detachment, Vietnam, in the unit's courtyard at Long Binh, October 1967. U.S. Army photograph. Public domain. EPH in Vietnam 1.jpg Copy. October 1967. Thank you, Ladies.

"I was always fearful of what's behind me. So I acted kind of strange when I came home because I was plucked out of a combat and jungle environment and firefight, and I got on a plane and came home. I tried to drink myself to death. Ended up in the emergency room, and un, it was time for me to go get some help. That kind of saved my life."66

In 1988, the National Vietnam Veterans Readjustment Study (NVVRS) of a representative sample of 1200 veterans estimated that 30.9% had developed posttraumatic stress disorder (PTSD) during their lifetimes and that 15.2% were currently suffering from PTSD. The study also found a strong dose-response relationship: As retrospective reports of combat exposure increased, PTSD occurrence increased. Skeptics have argued that these results are inflated by recall bias and other flaws. We used military records to construct a new exposure measure and to cross-check exposure reports in diagnoses of 260 NVVRS veterans. We found little evidence of falsification, an even stronger dose-response relationship, and psychological costs that were lower than previously estimated but still substantial. According to our fully adjusted PTSD rates, 18.7% of the veterans had developed war-related PTSD during their lifetimes and 9.1% were currently suffering from PTSD 11 to 12 years after the war; current PTSD was typically associated with moderate impairment.67

Suicide Rates During and After the Vietnam War 

Alexander Paul contacted Point Man International, a Christian organization for veterans, to conduct a phone interview with a retired V.A. doctor. In that interview, the doctor estimated the number of Vietnam Veteran suicides at 200,000 men. The reason for the lower documented suicides primarily involved single-car drunk driving accidents and self-inflicted gunshot wounds but didn’t leave a suicide note or statement. According to the doctor, the under-reporting of suicides was primarily an act of kindness to the surviving relatives. 

If the estimate that over 150,000 veterans of the Vietnam War have committed suicide since returning home is accurate, the figure would be almost three times the number killed in the war. When adding these deaths to the 50,000 plus Vietnam War dead, the number approaches the 292,000 American “combat deaths” of the Vietnam War.

The latest C.D.C. figures for the suicide rates in America from 1999 to 2010 discovered an increase of 28% in middle-aged U.S. citizens. Out of every 100,000 adults between ages 35 to 64 who committed suicide, it increased from 13.7 to 17.6 suicides. Many suicides arose from ages 50 to 54 (48%) and 55 to 59 (49%).68

But suicide rates among Vietnam veterans are the highest of any particular group, according to John Draper, project director of the National Suicide Prevention Lifeline.69

A man and woman sit watching archival documentary footage of the Vietnam War on Television

Leffler, Warren K. Public domain. Watching Vietnam War Footage.jpg Copy. January 1, 1968

Treatment 

The American Psychiatric Association released DSM-II in 1968 without listing the symptoms, signs, or definitions for “combat stress.” These omissions made it difficult to treat those returning home. Veterans began showing post-battle signs but without treatment. The doctors had no comparable evidence on which to base the symptoms and, therefore, no way to determine the best therapy. Without proper treatment, the Vietnam War veterans began self-medicating with drugs and alcohol. 

Researchers at the Harvard School of Public Health, Columbia University, The American Legion, and the State University of New York (SUNY) Downstate Medical Center surveyed 1,377 American Legionnaires who had served in Southeast Asia.

The findings from the study mandated by Congress in 1983 were alarming. At the time of the study (middle- to late-1980s), among Vietnam veterans, approximately 15% of men and 9% of women were found to currently have PTSD.

Approximately 30% of men and 27% of women had PTSD at some point in their life following Vietnam.

Their study found that almost three decades after the Vietnam War, many veterans continued to experience problems with PTSD. At the initial interview, approximately 12% had PTSD. Fourteen years later, the rates of PTSD had dropped only slightly to approximately 11%. Those who had experienced high levels of combat exposure were most likely to have PTSD at both interviews.

Veterans who continued to have PTSD 14 years after their first interview were found to have considerably more psychological and social problems.

They reported lower satisfaction with their marriage, sex life, and life in general. They also indicated having more parenting difficulties, higher divorce rates, lower happiness, and more physical health complaints, such as fatigue, aches, and colds. Veterans with chronic PTSD were also more likely to be smokers.

_________________

66 From an Iowa PBS documentary, "Post-Traumatic Stress Disorder (PTSD) and Vietnam Veterans." I pulled this off of the internet. No name other than "Gannon" in this 2:30 minute video. (accessed Mar. 8, 2024).

67 Bruce P. Dohrenwend, J. Blake Turner, Nicholas A. Turse, Ben G. Adams,4 Karestan C. Koenen, and Randall Marshall, "The Psychological Risks of Vietnam for U.S. Veterans: A Revisit with New Data and Methods," Science 18 313 (Aug. 2006): 979–982. (accessed Mar. 8, 2024).

68 Susan D. James, “Suicide Rate Spikes in Vietnam Vets Who Won't Seek Help.” ABC News, May 3, 2012. (accessed January 29, 2015).

69 Ibid.

70 Matthew Tull, PhD, "The Long-Term Impact of PTSD in Vietnam War Veterans," verywellmind, Updated on July 08, 2021. (accessed Mar. 5, 2024).

___

Gulf  War (1991); Iraq and Afghanistan War (2002 to present)

U.S.A. Today reports that the Pentagon has officially listed 2,355 service personnel as killed in action in Iraq and Afghanistan since the start of those wars. Approximately 697,000 U.S. Veterans served in the Persian Gulf War, and more than 263,000 have since sought medical care at the Department of Veterans Affairs. Over 185,000 have filed claims with the Veterans Administration for service-related medical disabilities, including significant physical and psychological distress attributed to their participation in the operations.71

1Demolished vehicles line Highway 80 on 18 Apr 1991.jpg Gulf War in Iraq. USAF photo by TSgt. Joe Coleman. Public domain. [[File:1Demolished vehicles line Highway 80 on 18 Apr 1991.jpg|. August 18, 2006. The U.S. Department of Veterans Affairs estimates that P.T.S.D. afflicts: 

• Almost 31 percent of Vietnam veterans

• As many as 10 percent of Gulf War (Desert Storm) veterans 

• 11 percent of veterans of the war in Afghanistan

• 20 percent of Iraqi war veterans

The Iowa Persian Gulf Study Group discovered that 2% of Gulf War veterans had P.T.S.D. From 4% to 9% of Army veterans, after returning home, developed psychological symptoms within the first five days of arrival. The highest-risk veterans with P.T.S.D. were females because they already had “pre-combat abuse history.” Subsequent studies revealed that rates of P.T.S.D. increased as time passed, 3% for men and 8% for women.72 

Trauma exposure is a significant concern, as it leads to poor health outcomes in veterans. When investigating PTSD in GWVs (Gulf War Veterans), Barrett et al.73 found that endorsements of fair to poor health statuses were common, as were lower quality of life due to health-related difficulties. Gade and Wenger74  found that GWVs exposed to dead, dying, or injured people exhibited a higher need for mental health services, even after controlling for demographic characteristics, social economic status, and insurance coverage. Engel et al.75 investigated how PTSD impacted physical symptom reporting amongst GWVs, and found that GWVs diagnosed with PTSD reported more physical health symptoms over veterans with other psychiatric disorders and healthy veterans. Wachen et al. found significantly increased physical symptoms in veterans with posttraumatic stress symptomatology as measured before and after the war. Posttraumatic stress symptomatology was identified as a mediator between war zone exposure and physical health, impacting all physical health domains tested (i.e., cardiovascular, dermatological, gastrointestinal, genitourinary, musculoskeletal, neurological, and pulmonary). Therefore, PTSD is a significant concern when considering GWI as it is also contributing to poor health presentation.76

Chris Bowen

Seattle King 5 NBC Reporter: "Chris Bowen served in the Gulf War leading a platoon of 43 soldiers across the Saudi desert. They delivered troops and supplies. He spent nearly A year in the war zone, and when he finally came home, he was not the same man."

Chris Bowen: "It is difficult to think that we were part of a machine that caused that much damage. There are certain times you have to take action that is not consistent with what you do back here. And then all of a sudden you have to go, wait, you know, that piece was me."

Seattle King 5 NBC Reporter: "So for the past six years now, Chris has been committed to weekly counseling every week, never misses a week. And this is how he's managed to live with post-traumatic stress. So what's last year been like?"

Chris Bowen: "Last year, it's been good. Counseling has been good, but also it stirs up more stuff also. So you're learning to deal with more issues that some of the issues I've probably forgotten or haven't thought about in a while. People that have PTSD as well as people that didn't know that I had PTSD. That's one of the things is the shame, but I've had overwhelming support." 

Seattle King 5 NBC Reporter: "Why is that important?"

Chris Bowen: "Because we're suffering and we need help."

Seattle King 5 NBC Reporter: "Now, post-traumatic stress for you manifested many years after you returned from the Gulf War, about 17 years. That's not uncommon, is it?"

Chris Bowen: "I don't think so. I'm finding out more and more that it is not uncommon, that some people, our minds are able to block things away and then they come back and they come back in different ways for different people."

In fact, in one recent meta analysis of thirty-two scientific articles, researchers found the estimated incidence of PTSD among veterans ranged from modest figures such as 1.09% to high rates 34.84%. Clearly, determining the true prevalence of PTSD among veterans will require much further research.77

Collage of images taken by U.S. military in Iraq. Compiled by the uploader. Public domain. Iraq header 2.jpg Copy. October 10, 2007

There is a 12.9% incidence of PTSD among U.S. veterans as compared to an estimated 6.8% lifetime prevalence of PTSD among the general population. According to Hill & Ponton, 87% of veterans have experienced traumatic situations that potentially might cause PTSD. The average number of events veterans experience that may lead to a diagnosis of PTSD is 3.4%.78

Transition Risks

A 2018 study of 722 veterans living in the San Francisco Bay Area. "Sample items include 'In the past month, how much were you been bothered by: Repeated, disturbing, and unwanted memories of the stressful experience?' and 'In the past month, how much were you been bothered by: Feeling jumpy or easily startled?'"79

The Posttraumatic Stress Disorder Checklist 5 delved into three veteran areas. 1) Combat experiences; 2) Discharge status; 3) Social connectedness.

The study considered factors in a veteran's transition from military into civilian life and "Re-establishing a new sense of community." Relevant agencies that do not address these two domains may contribute to at-risk circumstances for veterans developing PTSD after leaving the military. "Combat experiences and non-honorable discharge status were also found to have an indirect effect on PTSD symptoms through their effects on social connectedness. This means that while these factors are present, they not only act on PTSD directly but also indirectly by inhibiting social connectedness." The prevalence of PTSD among veterans ranges from 11 to 30% based on the area of service. Research indicates that an estimated 30% of Vietnam, 10% of Gulf War, 15% of Iraq veterans, and 11% of veterans returning from Afghanistan struggle with PTSD.80

The study revealed the possibility that the lack of "social connectedness" plays an important role "related to PTSD in veterans." Social connectedness directly affects PTSD symptoms. If veterans don't feel socially connected, their symptoms are impacted to a greater extent and thus inhibit social relationships.

Suicide Rates During and After the Iraq and Afghanistan Wars 

From October 7, 2001, to the end of December 2005, 144 veterans took their own lives. Of this number, twenty-four percent, or 35 vets, served in the Reserves, while 41 served in the National Guard. Sixty-eight of the 144 were active military/regular Army. 

Per researchers’ estimates, 30,177 Global War on Terror veterans have died by suicide, compared to 7,057 who have died while deployed in support of the Global War on Terror.81

After a VBIED Iraq War 2007-2008. jpg Copy Member of the 187th Infantry Regiment. Public domain. between 2007 and 2008

In 2021, 6,392 Veterans died by suicide, an increase of 114 suicides from 2020. When looking at increases in rates from 2020 to 2021, the age- and sex-adjusted suicide rate among Veterans increased by 11.6%, while the age- and sex-adjusted suicide rate among non-Veteran U.S. adults increased by 4.5%.82

During the COVID-19 pandemic, Veterans were found to experience more mental health concerns than non-Veterans. A systematic review of 23 studies found increases in the prevalence rates of alcohol use, anxiety, depression, posttraumatic stress disorder, stress, loneliness and suicidal ideation. The results of this systematic review found key risk factors to include pandemic-related stress, family relationship strain, lack of social support, financial concerns and preexisting mental health disorders.83

Age- and sex-adjusted suicide rates were higher among Recent Veteran VHA Users (VHA Veterans) than for Other Veterans.

• From 2001 to 2021, age- and sex-adjusted rates increased by 40.1% for Recent Veteran VHA Users and by 73.7% among Other Veterans.

• From 2020 to 2021, adjusted rates among Recent Veteran VHA Users increased by 13.9% and rates among Other Veterans increased by 10.2%.

Treatment 

Wolfe, Keane, and Young have made several suggestions for treatment for Gulf War vets. The scope of the veteran’s traumatic experiences needs attention paid to it. Clinicians must focus on a veteran’s pre-military as well as post-military stressors. Suppose a veteran had a history of abuse or trauma before service. In that case, exposure to severe stressors during combat could contribute significantly to the development of P.T.S.D. in the war zone and post-military separation. This exposure described my situation. 

The passing of the National Suicide Hotline Designation Act of 2020 provided a critical pathway forward for expanding ease of access to the National Suicide Prevention Lifeline, now the 988 Suicide & Crisis Lifeline, and VCL with a 3-digit number (Dial 988 then Press 1 for VCL). VCL is an important part of VA’s public health approach to address Veteran suicide as it is for all Veterans, not only those engaged in VHA services. . . . From 2021 to 2023, VCL continued preparing for the implementation of 988, hiring over 900 individuals. From the launch of 988 on July 16, 2022, through June 30, 2023, VCL fielded nearly 1 million contacts, including over 750,000 calls — an increase of 12.5% compared to the same timeframe from the previous year and with an average speed to answer of 9.4 seconds. In addition, there was a year-over-year increase in text messages (45%) and online chats received (8.6%). This increase in contacts reflects the work of the VCL campaign to share the message of the easier way to reach VCL through 988, then Press 1. The VCL communications campaign provided specific resources for connecting to care as well as nationwide messaging resources through the VeteransCrisisLine.net/Spread-the-Word site. . . . VCL also expanded its services in 2021 with the establishment of its Peer Support Outreach Center (PSOC) to provide support, hope, and recovery-oriented services to Veterans beyond their initial VCL call.84

Conclusion

As someone who has participated in the U.S. V.A.s Mental Health PTSD programs in four different states, our system far exceeds any other nation assisting its military in sorting out the intricate nature of combat traumatic stress. The doctors and assisting personnel are second to none in commitment to the needs of veterans. For example, when I traveled to Ukraine to teach in 2003 and ended in 2018, I found that the Ukrainian veterans who fought against us in S. E. Asia received free trolley bus service for life. The end. That was it. No healthcare. There is no doubt that millions of veterans have been helped and lived better lives because of their treatment at their local veteran's clinics and hospitals. 

My interest in this subject is not merely the research and its findings. From a Biblical, Reformed, and Confessional standpoint, teaching coping and maintenance techniques while dispensing medications, providing veteran group dialogues, and one-on-one sessions with mental health professionals is not sufficient.

Not once during my stay in these national V.A. facilities and programs did any of the veterans give me any indication that the particular program was having a profound or even rudimentary impact on them for good. I came away as unimpressed, and at the Sioux Falls and Denver V.A. PTSD programs, I was as melancholy as when I entered. Not because I didn't want to gain from them. The people in charge view psychology and man's one-dimensional existence as the only adequate worldview. This life is all there is. We're all descended from apes, and therefore, we are merely intelligent animals. God doesn't exist. When asked if he believes in God, one healthcare professional said, "If someone is healed, that's God," whatever that means. 

Note the following Emory Healthcare System documentary. 

Lt. Col. Ken Gillis: "I originally went in the Marine Corps in 1987." 

Emory HCS Narrator: Lieutenant colonel Ken Gillis spent the next 28 years leading. 

Lt. Col. Ken Gillis: "I loved everything about it, and I love the extreme experience of combat." 

Narrator: Lt. Col. Gillis deployed to the Middle East five times beginning with Iraq in 2003. 

Lt. Col. Ken Gillis: "You do enough tours, you see a lot of death. When you're in a leadership position, you don't have the luxury of emotions." 

Narrator: Home, Lieutenant Colonel Gillis realized he was suffering from PTSD, with thoughts he couldn't shake or move past. There was training for war. There was no training for how to adjust to life after war, where normal things appeared as threats. 

Lt. Col. Ken Gillis: "I didn't like cars near entrances. I didn't like people or groups of people loitering around areas. I didn't like to have my back to entrances or exits." 

Narrator: Years into his struggle with PTSD he heard about Emory Healthcare Veterans Program. 

Lt. Col. Ken Gillis: "I said, you know, someway, somehow, I owe it to my family to be the best version of me I can be." 

Dr. Barbara O. Rothbaum, one of the professionals at Emory University Healthcare Program for Veterans, says, "There is really no way to the other side except to the pain, but it really doesn't take that long. Most of her treatments are very effective and anywhere between six and 12 sessions. Lieutenant Colonel Gillis received individualized assessment and treatment in an intensive two-week program. His team included professionals in psychiatry, neurology, physiology, social work, and other fields. 

Lt. Col. Ken Gillis: "I think that you need think about the program. They look at all the issues you are dealing with and they work in a team environment, and pull all that together and see basically where you're at now and where you need to go in the future to be thriving and successful." 

Narrator: Fellow veterans work in the program on the outreach and clinical side lending a depth of understanding of military life from one-on-one therapy to yoga. Lieutenant Colonel Gillis embraced Emery veterans program, but it was on a program outing to the (Atlanta) aquarium that served as a breakthrough for him.

Lt. Col. Ken Gillis: "The whale shark comes right at you . . ." 

Narrator: His trip beneath the surface reminded him of a beauty still to be found in his life. 

Lt. Col. Ken Gillis: "It's an incredible experience. And they get you to see life's possibilities, like wow, there's a bright, beautiful world out there. Look at this. Go out there and experience it and thrive in it."

Narrator: After a decade of Band-Aids, Lieutenant Colonel Gillis began to truly heal the invisible wounds of war. His wife and daughter and son had their husband and father back. 

Lt. Col. Ken Gillis: "They would probably tell you that the transformation's remarkable." 

Narrator: Ever the leader Lieutenant Colonel Gillis joined the Marines because he wanted to be the best. He still wants the best for those he led. You know, the Emery program, I just wish every veteran could go through this that's struggling with PTSD; they could go through and go say there is hope, there is a way through this, and come out on the other side better. I think the program gave me the opportunity to have my life back.

There is no way I would disparage such incredible work by these professionals on behalf of the veterans they serve. Praise God that He has provided such mercy to believers and non-believers alike. Matthew 5:45 tells us, for He causes His sun to rise on the evil and the good, and sends rain on the righteous and the unrighteous. Amen. But as the Christian knows, for the self-righteous who do not need a Savior from sin and its guilt and bondage, the best Emory Healthcare or the V.A. can offer is still a continuation of spiritual bankruptcy. The patient merely feels better about themselves right up to their death or the moment when they face the unquenchable, eternal wrath of God. 

Nor is there any mention of how the Church needs to become part of the solution via the means of grace. There are multiple reasons for this neglect, chief of which is the distrust many professionals have in the Church's ability to help veterans through grace. Most pastors have no idea how to address traumatic stress and the veterans' struggle with it. As a seminary grad, the counseling class I took didn't venture into the area of veterans' needs. That class aimed at "normal" Christians with "normal" problems.

I hope that through my Podcast and website, a ministry to veterans, First Responders, battered women, and children who suffer to a greater or lesser degree from PTSD might come into vogue.

_______________

71 “Gulf War Veterans 10 Years Later.” Week of May 28, 2007. (accessed November 21, 2014).

72 Iowa Persian Gulf Study Group, The. “Self-reported illness and health status among Persian Gulf War Veterans: A population-based study.” JAMA 277, (1997). (accessed November 5, 2014).

73D.H. Barrett, G.C. Gray, B. Doebbeling, D.J. Clauw, W.C. Reeves, "Prevalence of symptoms and symptom-based conditions among Gulf War veterans: current status of research findings. Epidemiology Review 24 (2002):218–27, in Mary Jeffrey, Fanny Collado, Jeffrey Kibler, Christian DeLucia, Steven Messer, Nancy Klimas & Travis J.A. Craddock, "Post-traumatic stress impact on health outcomes in Gulf War Illness," BMC Psychology 9, 57 (2021) https://doi.org/10.1186/s40359-021-00561-2. (accessed 7, 2024). 

74D.M. Gade, J.B. Wenger, "Combat exposure and mental health: the long-term effects among Vietnam and Gulf War veterans," Health Economics 4 (2011):401–16, in Mary Jeffrey, Fanny Collado, Jeffrey Kibler, Christian DeLucia, Steven Messer, Nancy Klimas & Travis J.A. Craddock, "Post-traumatic stress impact on health outcomes in Gulf War Illness," BMC Psychology 9, 57 (2021) https://doi.org/10.1186/s40359-021-00561-2. (accessed 7, 2024).

75 C.C. Engel, X. Liu, B.D. McCarthy, R.F. Miller, R. Ursano, "Relationship of physical symptoms to Posttraumatic Stress Disorder among veterans seeking care for Gulf War-related health concerns." Psychosomatic Medicine 62 (2000):739–45, in Mary Jeffrey, Fanny Collado, Jeffrey Kibler, Christian DeLucia, Steven Messer, Nancy Klimas & Travis J.A. Craddock, "Post-traumatic stress impact on health outcomes in Gulf War Illness," BMC Psychology 9, 57 (2021) https://doi.org/10.1186/s40359-021-00561-2. (accessed 7, 2024).

76 Ibid.

77 Hill & Ponton, "PTSD and Veterans," (accessed Mar. 7, 2024).

78 "Risk factors associated with posttraumatic stress disorder in US veterans: A cohort study," PLoS One 12(7) (2017): e0181647.

79 PTSD Checklist for DSM-5 (PCL-5).

80 Muller J., Ganeshamoorthy S., Myers J. Risk factors associated with posttraumatic stress disorder in US veterans: A cohort study. PLoS ONE 12 (2017):e0181647; Richardson L.K., Frueh B.C., Acierno R. Prevalence estimates of combat—Related post-traumatic stress disorder: Critical review, Australian & New Zealand Journal of Psychiatry 2010;44:4–19; Knowles K.A., Sripada R.K., Defever M., Rauch S.A.M. Comorbid mood and anxiety disorder and severity of posttraumatic stress symptoms in treatment seeking veterans. Psychological Trauma (2018):1–8, in Sara Kintzle, Nicholas Barr, Gisele Corletto, and Carl A. Castro, "PTSD in U.S. Veterans: The Role of Social Connectedness, Combat Experience and Discharge," Healthcare (Basel) 6(3) (Sept. 2018): 102.

81 Meghann Myers, "Four times as many troops and vets have died by suicide as in combat, study finds," MilitaryTimes, June 21, 2021. (accessed Mar. 7, 2024).

82 2023 National Veteran Suicide Prevention Annual Report, U.S. Department of Veterans Affairs, 5. (accessed Mar. 7, 2024).

83 Ibid., 7.

84 VA Suicide Prevention 2022, Office of Mental Health and Suicide Prevention September 2022.

85. R. Ramchand, L.H. Jaycee, P.A. Ebener, "Suicide Prevention Hotlines in California: Diversity in Services, Structure, and Organization and the Potential Changes Ahead," Rand Health Quarterly 19 (6) (2017): 8, in 2023 National Veteran Suicide Prevention Annual Report, U.S. Department of Veterans Affairs, 42. (accessed Mar. 7, 2024).