02 February 2011

Post-Traumatic Stress, Then and Now

One poster at Tom Ricks' Best Defense asks why it seems that the current generation of soldiers seems to experience Post-Traumatic Stress more than their predecessors.  Might the current generation of soldiers come from a more sheltered lifestyle, he muses?

The responses are excellent.  Suffice to say that few realize that PTSD has been observed as far back as Herodotus, and that a whopping 98% of World War Two veterans experienced some sign of psychological disturbance after thirty-five days of constant combat.  Nor is PTSD a solely military phenomenon:  rescue workers have been known to experience it, as well as victims of sexual trauma, and even railway accidents.

Without further ado, some great message board comments.

Gold Star Father:
[PTSD has always been] there and in numbers reflecting the volume of veterans from any war.
I have researched the deaths of veterans in my area from 1945 to 1950. The number of shattered lives and families, crimes committed, and deaths by alcohol and auto amazed me. I think we hear about it currently, beacause it is talked about so much. "Post Traumatic Stress Disorder", as an affliction with that title, has been 'in the system' but for less than 30 years.
Iron Captain:
PTSD has always existed. Vietnam Vets had it. WWII vets had it. Civil War vets had it. War sucks. It is traumatic. It effects the people involved. Some get better. Some do not.
PTSD was not well understood until behavioral health specialists started studying it after Vietnam. The creation (and politization) of the term came about in the early eighties and the creation of what became the Department of Veterans Affairs.
The "PTSD story" is often a hook in news stories, because it ties one person's problem with our wars in Iraq and Afghanistan. There might be slightly more PTSD today than in Vietnam because of the All Volunteer Force and a small slice of troops who have deployed too often without enough down time (or dwell time) but I doubt the rates are much different.
Vietnam, Korea, and WWII vets had problems when they returned. They drank. They got in fights. They beat their wives. We now understand that some of those behaviors might have been related to problems with PTSD. Or they might have just been people given to such behavior regardless. Some people get better. Some people do not.
The reason the military talks about such things and that it is discussed so often in the press and among ourselves is that we are trying to deal with this. We are understand PTSD much better now than we did in previous eras. The Marine Corps was teaching its Infantry Officers about PTSD in its "Killology" class years before September 11th. The other services are catching up and everyone understands it better now, but we are still learning. The system is getting better, with counseling and leadership that understands the problem more. But the system is imperfect.
I don't think that the guys who fought in Fallujah or the Korengal are any less tough than the guys who fought in the Argon or Chosin. I would not dare to make a comparisonout of respect for the vets of any era. We all did our bit and did the best we could to move on with our lives afterwards. Some of us had it rougher than others. Some of us adjusted better than others.
There is not more PTSD, just more PTSD coverage.

IRR Soldier:
You raise some interesting points. I don't have the answers per se, but let me contribute the limited reaserch I've done on this issue.
While your father-in-law (and my own great uncle) may have been in the ETO for nearly 4 years, they were not in sustained combat during all of that time. Right off the bat, that was one huge difference between then and today's 1:1 deployment cycle. The WWII Division with the most days of cumulative combat time was the 32nd ID - 654 days. It is worth noting that this time adds up to well less than 2, 1 year deployments to OIF/OEF. So, while the intensity of combat today may be less than WWII, initial first term soldiers are frequently seeing cumulative combat exposure that exceeds the time endured by the most exposed division in WWII. There is no rear area, there is no (legal) outlet for sexuality and there is no beer.
As early as 1943 we knew that prolonged tours had a devastating impact on the morale and neuropsychiatric health of infantrymen. Post war research showed that based on ETO casualty rates, 180 days of cumulative combat exposure represented the "burn out" point for front-line troops. In WWII, soldiers with >180 days of cumulative combat exposure had psychiatric casualty rates higher than new replacements.
The individual replacement system (seen in Korea and Vietnam) was designed in the wake of WWII as a means of decreasing psychiatric casulaties. Despite its mixed record in Vietnam, as late as 1988 articles in Army professional journals expressed doubt that we would ever return to a unit based rotation system.
Well, it's 2011 and we are stuck with a unit based rotation system. This system puts the well being of the unit over the individual soldier. The unit based system relies on things like stop-loss, the redeployment of soldiers with less than a year back stateside and the multiple deployment of first term soldiers and Marines.
In Vietnam, a first termer never had to go back unless they reupped or volunteered to. Not so today. Also, the transition to the AVF ushered in the era of the 4 year enlistment contract as the "norm" (up from a 2 year draftee contract and the 3 year RA volunteer). This ensures that first term soldiers and Marines can deploy multiple times before getting the chance to say "no more." This is important. A first term 11B in 1968 just had to survive 365 in Vietnam before getting a chance to exercise his informed decision to "stay" or "go." Today in the 101st or 10th Mountain, you survive your 365 days and all you have is another 365 days to look forward to before you can ETS. This really messes with the head. The light at the end of the tunnel is a looong way off.
Also worth noting is the change in 1984 that increased the total Military Service obligation (MSO) for all personnel from 6 to 8 years. This means that kids who did 2 combat tours in their initial 4 year hitch aare almost guaranteed to be recalled during their 4 year IRR time to go back again.
These are just a few, random data points that I wanted to share.

And, finally, from Hunter:
PTSD or shell shock or battle fatigue existed in much greater numbers than people realize in all those earlier wars you cited. But the guys who survived it and were functional didn't talk about it, and those who survived it but weren't functional probably aren't in the circles we all travel in. They're part of the dysfunctional populace in homeless shelters and VA hospitals.
Second easy one is that like politics all wars are local. In other words it doesn't matter how many guys died in WWII or Vietnam, the stressors that soldiers experience in combat are all local in nature and relevant. In Iraq and Afghanistan it doesn't matter that only (only?) 5000+ people have died...esp. if every day you or your buddy is getting blown up by IEDs. It's scary, it's day to day, and it doesn't go away. And then you go home, redeploy and do it all over again.
Things start to get dicey after that. Your father-in-law may have done 4 years in Europe but he didn't do 4 years straight in combat. They tended to rotate units off the line back then and they recognized that 90 days was about what they could do before they were psychological casualties. The warfighters today tend to have more stop and go than that but they also probably have more 'threat' time in total. (This is dicey because it gets really hard to draw comparisons).
As for the amenities our soldiers have (which I've advocated against here before), there is a cost benefit to that too. The first obvious, but somewhat incongruent, one is that instant communication back home isn't all good. Soldiers don't get to get away from their problems at home, they are waiting for them on the Skype when they get back from patrol. They get a whole set of different stressors - like the bills that can't be paid or the problems with Johnny Jr. As late as '96 in Bosnia it still took me 30 days to get mail and hear about my girlfriend's issues, now you get that immediately. They also tend to rely on going to the computer instead of talking to their mates about what happened that day - which may be one of the most important factors in preventing this problem. History (and Dave Grossman) tell us that campfire stories and the lack of night fighting in earlier wars were inherent to the idea that soldiers decompressed after each day's fight. They shared their concerns, and realized (most importantly) that they were ALL undergoing the SAME thing.
Because we are more insulated and isolated as a society, because our soldiers retreat to the phone banks or Skype, they may not be getting the decompression they need. It's great to talk to the wife, but the fact is you won't generally share what happened with them because a) they don't understand b) you don't want to scare/worry them. So Johnny is marching alone. Because you are alone there is stigma associated with asking for help too.
Another factor in this decompression was travel times. In WWII your FIL probably took a month on a boat to get back to the U.S. That's a long time to decompress and come to grips with your demons. And you did that trip in the company of your squad mates. Now it's 24 hrs to a warzone by plane and we don't do an adequate job of forcing decompression back stateside - the last place you want to be is on post, you want to be drinking and sexing (sorry it is what it is). Or you want to be with family, anywhere but with the guys you spent the last year with.
Finally I'll say that technology and medical science has done us some questionable favors along the way. Soldiers in body armor, or who receive rapid medical care are surviving wounds they probably shouldn't. That's obviously in God's hands but it's clear with more survivors of more grevious wounds that commensurate mental health problems will come along with it.
I could go on and on offering ideas on why PTSD seems more prevalent, but my summary is a) it probably is no more prevalent just more recognizable and diagnosed b) if it is more prevalent it is because a myriad of social factors, which I don't think include "toughness." These wars are different than those preceded. Not harder, not easier, just different.
In the end as I stated in a previous post, PTS is a normal thing, it is how we react individually and collectively that sets the conditions for PTSD. There's alot more attention to things now, and greater understanding but we don't have all the answers by any means.


greg said...

I just finished reading With the Old Breed by EB Sledge about his time with the 5th Marines on the front lines at Pelileu and Okinawa, and he directly addresses the topic of 'combat fatigue' several times. His description of the conditions in which they fought and lived and the various reactions that his fellow Marines had to that is simply amazing. I have a hard time believing that anyone who served on the front lines in situations like that could have left without some degree of PTSD. He also discusses why it may have affected different people differently -- the severity of the discipline of the training he went through being one of the biggest limiting factors, especially when compared to later replacements who had had an abbreviated training regimen prior to being sent to the front lines. But he also said that no matter the training, the stress would always get to people, and did so in various ways.

If you haven't read that book yet, I highly recommend it.

Starbuck said...

Gonna Kindle it right now. Thanks.

Leigh said...

an interesting question. in addition to the excellent observations you quoted, i'd like to briefly mention some things we're thinking about on the R&D side. the technological advances we've seen over time have changed the nature of wars over generations. of note for the present conflict(s), for example, is the prevalence of repeated blast overpressure exposures and resulting TBI of varying severity. in turn, the evolution in protective technology is helpful for us in the sense that we bring more of our people home, but when we have more survivors a greater proportion of those survivors are going to come home with trauma-related brain injuries/psychological injuries. PTSD is almost surely a subtle and complex brain injury in and of itself, but we are still pretty heavily in the dark as to the specifics...

Alex Brown said...

Nice blog. Thanks for sharing it.

Daniel said...

Thanks for sharing information..and I'm gonna Kindle right now... Thanks again.