The recent Fort Hood tragedy is beginning to shed more light on how the medical profession handles psychological stress before, during and after combat.
Much remains unclear about Maj. Nidal Malik Hasan, the Army psychiatrist who military officials said gunned down dozens of soldiers in Texas. After counseling soldiers returning with gruesome tales of war, he was reportedly dreading deployment himself.
Yet though his motives are still just speculation, five of the 13 people he killed were fellow therapists, the Army has reported.
Such stress has been noted for centuries, but it is only recently that doctors and therapists have begun to react more quickly and effectively to treat symptoms. The Pentagon is assigning more counseling staff to units in Iraq and Afghanistan, and post-combat medical attention is more immediate and more intensive.
In previous conflicts involving American soldiers, battle fatigue and shell shock remained common terms used by psychiatrists and even military leadership to describe the immense psychological toll that warfare took on soldiers. It was even considered by some to be a sign of cowardice.
Gen. George Patton reportedly slapped a solider who showed signs of mental duress, criticizing the soldier’s lack of toughness.
The Military Veterans Post-Traumatic Stress Disorder Reference Manual notes that the term “post-traumatic stress disorder” took some time to be officially classified as a psychological condition.
It has been named anything from “exhaustion” in the 1800s to “soldier’s heart,” “the effort syndrome” and “shell shock” during World War I and “combat fatigue” in World War II.
The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders – considered by some to be the bible of psychiatry – lists PTSD as a stress response and anxiety disorder.
Wayne Anderson, MU professor emeritus of psychology, has studied and worked extensively with patients suffering from traumatic stress. He has experience with not only military personnel but also rape victims and civilians suffering in conflict areas such as Kosovo, Bosnia, Pakistan and the Gaza Strip.
“We had all kinds of other names for it – battle fatigue, shell shock,” he said. “We didn’t have it down as orderly symptoms, and we didn’t put it under the title of PTSD.”
In Columbia, the Harry S. Truman Memorial Veterans’ Hospital Home has noted a change in the awareness of post-traumatic stress disorder in returning combat veterans in the last four to five years, leading to a change in treatment strategies.
L. Stephen Gaither, public affairs officer for the hospital, noted that there are singular factors in each war and that the numerous deployments of the National Guard and the Army reserve make the Iraqi and Afghan conflict different.
However, the increasing incidence of PTSD might be caused by increased awareness of its symptoms and its official title as a disorder.
“There may not be any higher incidence of PTSD, but there is a higher awareness of those symptoms and an ability to provide treatment,” Gaither said.
“You’re much more aware of that potential when you’re in that combat situation. There’s an increased awareness of symptoms, and it may not be individual but family members who identify that there is a problem.”
In the past, active duty soldiers were pulled from the front lines at the signs of difficulty coping with warfare. Cheryl Hemme, the behavioral health service line director at the hospital, said removing soldiers from the theater and returning them to their homes didn’t help the situation.
“It’s better to have mental health professionals embedded in the troops so someone in active duty or combat can try to deal with symptoms right then and there,” she said. “Once they pull them out and bring them home, it becomes more stigmatizing and difficult.”
Anderson finds that these individuals removed from combat encountered further issues once they returned home.
“A tremendous number of people who came back from Vietnam weren’t welcomed back into society and didn’t get appropriately assimilated,” Anderson said of those who returned to broken marriages, distant children and nonexistent jobs.
“They’re coming back to an environment that they’re not ready for. I think the government and people will pay much more attention to the incoming group now.”
Immediate response is part of the new arsenal of treatments to handle modern PTSD. Increasing resources for mental health services has become a national priority of the Department of Veterans Affairs, according to Gaither. The hospital provides care to more than 31,000 veterans in mid-Missouri, 1800 of those individuals combat veterans from Iraq and Afghanistan.
“All the resources, the added staff and the enhanced programs helps everybody do a much better job of addressing the needs of veterans and their families,” Gaither said. “Part of the resource request to the VA system was a direct need for a PTSD program.”
Gaither said the hospital was also doing a better job of reaching out to veterans to enroll them with VA health care. Forty-two percent of eligible combat veterans nationwide are getting care from the VA.
The 153 VA medical centers in the country provide screenings for combat veterans returning from active duty and repeat that screening annually to check for PTSD symptoms, depression and substance abuse. At Truman Memorial, screenings take place in what the hospital calls “seamless transition clinics.”
Hemme also emphasized the importance of through physical evaluations and combined psychotherapy sessions.
“It’s very important to look at the way their brain is reacting,” she said of veterans suffering from PTSD symptoms. “Classes and groups have been documented to be very helpful.”
Anderson notes that a situation must be “pretty horrifying” to create PTSD, depending on how close an individual is to the situation and how violent an environment becomes. Life and death struggles or very serious injury are usually involved.
After having worked as a hospital psychologist with the Veteran’s Administration from 1956 until 1963 and as consultant with VA from 1963 until 1981, he has observed that 70 percent of individuals who suffer intense trauma recover and return to normal psychological functioning after one year. The success of an individual in recovering after a year is known as resiliency.
However, it’s the 30 percent of individuals who don’t recover after serving in Iraq that he is concerned about. He described responses that those suffering from PTSD employ to deal with the trauma, including avoidance, suppression or blocking memories, nightmares and heightened alertness or overreaction. Anderson believes these figures to be accurate for those military personnel, but the figures can vary for other trauma victims.
Anderson believes that the diagnosis and treatment of PTSD has improved significantly.
“If you go back, most therapists wanted to talk about your childhood and raising and your history,” he said. “The modern therapist is focused more on how can we deal with the symptoms you’re dealing with – there’s not a lot of time spent on early history.”
Anderson also agrees with the method of collective therapy.
“Giving chronic patients responsibilities and group psychoanalytic therapy – the difference is highly significant,” he said.