With Changing Insights, Military Psychiatry Evolved Over Time

The link between the stresses of military life and the mental health of soldiers has occupied poets, doctors, and veterans since the Bronze Age, as any reader of Homer will attest.

Understanding of that connection has deepened over the last century, pushed by the era’s brutal, complex wars and greater insight into the experiences of those who fight them.

By studying this population over time, researchers have gained awareness of the long-term effects of wartime service on veterans. For instance, a 2006 study involving a random sample of 15,000 veterans of the American Civil War who applied for medical disability 40 years after the end of the war found that many of them had multiple cardiovascular, gastrointestinal, and/or nervous disorders.

“Nervous disorders” included what would be both psychiatric and neurological diagnoses today: psychosis, hallucinations, depression, mania, hysteria, suicidal ideation, and anxiety as well as aphasia, headaches, paralysis, epilepsy, and vertigo—symptoms that would not surprise today’s veterans.The link between the stresses of military life and the mental health of soldiers has occupied poets, doctors, and veterans since the Bronze Age, as any reader of Homer will attest.

Understanding of that connection has deepened over the last century, pushed by the era’s brutal, complex wars and greater insight into the experiences of those who fight them.

By studying this population over time, researchers have gained awareness of the long-term effects of wartime service on veterans. For instance, a 2006 study involving a random sample of 15,000 veterans of the American Civil War who applied for medical disability 40 years after the end of the war found that many of them had multiple cardiovascular, gastrointestinal, and/or nervous disorders.

“Nervous disorders” included what would be both psychiatric and neurological diagnoses today: psychosis, hallucinations, depression, mania, hysteria, suicidal ideation, and anxiety as well as aphasia, headaches, paralysis, epilepsy, and vertigo—symptoms that would not surprise today’s veterans.

Wars Bring With Them New Insight Into Psychiatric Symptoms

The part of the body believed to react to the stress of war has changed since the American Civil War. Then, problems were ascribed to cardiovascular anomalies. The strain of carrying heavy packs led to “disordered action of the heart,” it was believed, and a new diagnostic category, “soldier’s heart,” was created. More psychologically oriented physicians diagnosed “nostalgia,” an acute form of homesickness.

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These attempts at description reflected an increasing medicalization of war syndromes that took hold during World War I. The constant pounding of artillery was thought to disturb the neurons of the brain, inducing “shell shock,” which left soldiers immobilized. Many were evacuated to hospitals behind the lines or back to Britain.

Most of those soldiers never returned to battle, so a new tack was chosen. Soldiers with psychological symptoms were kept close to the front, given immediate help, and counseled that their condition was a normal reaction and neither pathological nor a personal failing, said Matthew Friedman, M.D., the former director of the Department of Veterans Affairs National Center for PTSD. Friedman is now a professor of psychiatry and vice president for research at the Geisel School of Medicine at Dartmouth College in Hanover, N.H.

Psychiatrist Thomas Salmon, M.D., sent to France with the American Expeditionary Force in 1918, studied how the British treated psychiatric casualties. He concluded that “shell shock” was an acute response to combat stress that could be addressed with the PIE approach: addressing the individual’s proximity (to the battlefront), immediacy (of care), and expectancy (of recovery), said Dale Smith, Ph.D., a professor of military medicine and history at the Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Md.

Much of the knowledge in dealing with psychiatric casualties in World War I was forgotten by the time of World War II. One glimmer of history was preserved in the research and writing of Abram Kardiner, M.D., a psychiatrist who observed American veterans in the 1920s and 1930s. In War Stress and Combat Neuroses, published in 1941, Kardiner described the emergence of hyperreactivity, stress intolerance, dissociative reactions, and altered physiology as these men faced the threat of war. “Kardiner did not let prevailing psychoanalytic beliefs obscure his observations,” said Friedman. “I consider him the father of the psychobiology of PTSD and other stress-related disorders.”

At the time of America’s entry into World War II, the U.S. Army was determined to minimize the psychiatric casualties seen in the previous war. Vulnerable recruits would be screened out using the prevailing psychoanalytic model. The result was failure; far too many otherwise healthy young men were screened out until the program was stopped. Nevertheless, psychiatric casualties—now called “battle fatigue” or “combat fatigue”—again occurred in the course of the war, sometimes at rates as high as 25% to 40%.

Understanding of PTSD Emerges

The PIE approach was eventually rediscovered, and general physicians in military service were given psychiatric training. William Menninger, M.D., head of the Army’s Neuropsychiatric Consultation Division, led the development of War Department Technical Bulletin Medical 203 in 1943, a manual that provided a useful classification system of mental illness and was later incorporated into psychiatric training, said Smith. With some tweaking, it was adopted by the Veterans Administration and ultimately by APA in DSM-I, providing a link between military and general psychiatry, said Smith.

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“The stigma attached to mental illness in the popular mind was not attached to a diagnosis of combat fatigue because the diagnosis had been ‘earned’ and thus conferred a measure of social protection,” he said.

The DSM-I brought forth “gross stress reaction” to describe the response to combat; it was later superseded by the more familiar “neurosis.” Gross stress reaction was not included in DSM-II in 1964, but the ensuing years saw two changes that focused and defined stress reactions. One was the growing body of literature based on careful observation of Holocaust survivors and rape victims, said Friedman.

“People working with different kinds of patients recognized commonalities in symptoms,” said Friedman. “They began focusing on the reaction, not the cause. In a situation that overwhelms the individual’s coping capacity, any person would have a similar pattern of symptoms.”

The second event was the war in Vietnam. The war itself was amorphous, lacking in front lines and realizable goals. Veterans were vilified as they came home. Many found comfort only among their own, in informal gatherings and eventually in veteran centers where they could process their experiences among themselves. Posttraumatic stress disorder (PTSD) was named and defined as a neuropsychiatric condition characterized by dysfunctions in learning and fear extinction. Treatments developed by Edna Foa, Ph.D., Patty Resick, Ph.D., and others using prolonged exposure and cognitive-behavioral therapy were adapted for veterans.

Vietnam veterans weren’t the first to experience PTSD, of course. “I’ve seen many World War II veterans,” said Friedman. “We weren’t asking the right questions [when they came home] because the PTSD construct hadn’t evolved. Risking your life in a war that makes sense may offer some protection, but that’s outweighed by the stresses of combat and the violent loss of friends.”

Preventing Psychiatric Casualties in Changing Circumstances

An increased understanding of the stresses of military life grew in the decades after the Vietnam War, said Col. David Benedek, chair of psychiatry at the USUHS. By the time of the Gulf War in 1991, medical detachments included combat stress control personnel deployed with combat units. They were trained to recognize a range of diagnoses beyond combat stress and could call on psychological and pharmacological treatments. They had a preventive mission as well, offering psychoeducation and sleep-management techniques, and helping officers understand the critical value of group cohesion and the need for social support.

In the more recent conflicts in Iraq and Afghanistan, the model was pushed even further. Recognizing the value of unit cohesion as a protective factor, troops in platoons and companies trained together, deployed to the war zones together, and returned home together. Behavioral health clinicians again were pressed further forward. Mental Health Advisory Teams were sent into the field to assess risk, especially following a spate of suicides among service members.

During the wars in Afghanistan and Iraq, there has been an uptick in the number of suicides by troops. Military populations are younger and healthier than the civilian population, and their suicide rates were historically lower, too. Yet, suicide rates in the Army rose above civilian levels over the course of the wars, from about 12 per 100,000 people per year at the start of the wars to 25 per 100,000 people years later. (According to the American Foundation for Suicide Prevention, the U.S. suicide rate in 2017 was 14 per 100,000 people.)

The correlation between suicide and combat is not clear. Troops who serve in the war zones have the same rates of suicide as those who had been previously deployed and those who had never been deployed.

To tease out this puzzle, Congress authorized $50 million for a massive study of thousands of Army (and later Marine) recruits. The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) gathered a variety of demographic, medical, social, and genetic information from 100,000 individuals. The data were analyzed to chart servicemembers’ passage through their military service.

“We set out to use machine learning techniques to create predictive algorithms and ultimately precision medicine,” said Robert Ursano, M.D., director of the Center for the Study of Traumatic Stress at USUHS and a principal investigator on the project. As Army STARRS progressed, the researchers learned more about the soldiers as they entered the service. Many had experienced traumatic events in their lives prior to enlisting, including many with traumatic brain injuries.

This led to increased emphasis in the armed forces on how the environment affects individuals and their subsequent mental health, said Ursano. Such knowledge allows better calculation of risk and the potential to develop interventions and offer better care.

The study examined 600 suicides between 2004 and 2009 but also found 10,000 suicide attempts, a separate problem that the military health system must also address, said Ursano.

The all-volunteer U.S. armed forces added another dimension in the years since the end of the Vietnam War. Women today make up about 15% of military personnel overall.

Care for women’s special medical needs—like menstruation or urinary tract infections in the field or pregnancy back in the United States—are a concern, said retired Army psychiatrist Elspeth Cameron Ritchie, M.D., M.P.H. The lack of front lines in the wars in Iraq and Afghanistan means that women, whether or not they are officially in combat units, are just as vulnerable to bullets, missiles, or roadside bombs as their male comrades. Those who work in medical units are exposed repeatedly to injured troops. The interaction of combat exposure with sexual trauma may exacerbate PTSD, although there are insufficient data so far to render a firm conclusion.

Psychiatrists who serve in military settings must learn the same things as their civilian counterparts, augmented by a military medical curriculum that includes battlefield training exercises for the days and months when they are working in combat. Finding a way to integrate those two streams is a key to future care for American troops during and after their service.

“American psychiatry underpins military psychiatry, but we haven’t yet tapped the full potential of psychiatry in the United States,” said Smith. “We need to create synergy between the two, and society needs people who will bridge that gap.” ■