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Long-term reactions of veterans to war experience

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Wybrand Op den Velde

Dr. med. Wybrand Op den Velde is head of the Psychiatric Department of the “Saint Lucas” Hospital in Amsterdam (Netherlands). He is medical adviser of the organization that takes care about Netherlands' resistance veterans (from the World War Two). He is the author of several studies about long-term consequences of exposure to heavy war stress.

Summary

The history of long-term post-traumatic reactions in war veterans is described. During World War I shell shock - a disorder with predominantly conversion reactions - was most commonly observed. Many veterans of the World War II suffered from combat exhaustion. In 1980, based on studies of American Vietnam War veterans, the post-traumatic stress disorder was introduced. The advantages and limitations of this new diagnostic category are discussed.
Keywords: veterans, traumatic neurosis, shell shock, combat fatigue, post-traumatic stress disorder, post-concentration camp syndrome.

Introduction

The history of post-traumatic stress reactions, which was shown by cunning observers of human life, is almost as old as mankind history. Examples of Achilles in Homer's Iliad, and Shakespeare's Hamlet are good known to the public (Shay, 1991).
It is the sad fact that the war thought us a lot about traumatic stress. In the armed conflicts people often been killed or wounded. The armies were using services of doctors, and their primary task was to ensure returning of wounded and sick to battlefield. It was mainly referred to physical injuries and sicknesses. However, during the battles, a lot of soldiers were put out of order because of emotional break-down. Military doctors were faced with solders that were not capable to execute their duties, because of psychical complications. Before World War One, psychical disorder, caused by battles was considered as act of weakness, cowardliness, or lack of military discipline.

World War One

If we came back to homes, from sufferings and frights that we experienced, we could cause the storm. Now, when we come back we are going to be tired, break-down, burned, without roots and hopeless. We will not be able to make shift any more... We are going to be needless to ourselves, we are going to get old, few of us will adapt, some of us will be surrendered, lot of us will be dizzy; years will pass, and we will be ruined in the end. (E. M. Remarque: Nothing new on the West).

During the World War One, German invasion to Belgium and France, got stuck in the mud of Flanders and North French. Armies were focused on mass artillery actions and gas attacks over soldiers that were fortified in ditches. Death came as the result of exploded grenades, gas poisoning and diseases. Large number of military losses during 1914-1918 were soldiers without significant physical injuries. They got disoriented and confused; with various symptoms like paralysis, analgesia, deafness, loss of memory, phobia, obsession, retch, laxity and insomnia. British military psychiatrist Myers introduced term shell shock to describe this state ( Myers, 1915). Mott; one of the leading experts of that time, believed that this state is caused by physical brain injury, caused by stunning changes of air pressure and Carbon Monoxide (Mott, 1916). Others, like Eder, believed that shell shock is caused by mental conflict, not by physical injury. Eder says: "It is hysteria that appears to soldiers that did not have psycho-neurotic disorders before, nor they were noted in their family records. Their spirit is more sensitive than the normal one." (Eder, 1918). Myers studied more than 2000 cases of shell shock. He concluded that the term shell shock was badly chosen, since disorder could be developed on soldiers that were not exposed to grenades. Latter he introduced two cases: shell shock and shell concussion. The latter one was causing hysteria, neurasthenia, followed with tremor and fear (Myers, 1940).

Honorable explanation was that soldier psychological problems had physical cause. Soldiers kept their self respect, and they got free of battlefield fright exposure. The authorities do not have to face themselves with unpleasant questions like war justification, military leadership quality and moral. Doctors avoid investigation of anxious possibilities like simulation and cowardliness (Van der Kolk et al., 1996.).

During the World War One, most of German psychiatrists considered war neuroses as special way of simulation, that is connected with deficiency of liking strength (Willenskrankheit; Fisher-Homberger, 1975).

Successful treatment of shell shock using hypnosis is described in literature. Currency treatment was popular, especially in Germany and Austria. Painful electric shock were used in combination with wealthy verbal suggestions (Niederbruellen, "discharge by howling"). The treatment was performed in military hospitals, in atmosphere of dominion and strict inferiority. It was usual to force curing on one session. By the reports, 98% of patients were cured, and they were considered as ready for duty.

Period Between World Wars

After the defeat in World War One, people in Germany and Austria felt degraded and deceitful. They were faced with hunger, delusion, hopelessness and chaotic future. They demanded punishment of responsible authorities. Temporary government in Austria founded special institution as response to this demands. It's task was to investigate bad leadership and disregard of military leadership duties. One of the charged was the famous psychiatrist. He was accused for supporting brutal and inhuman treatment of soldiers, including treatment of war neuroses with currency. The psychiatrist's name was Wagner von Jauregg, professor of psychiatry and neurology in Vienna. He discovered efficiency of Iodinated salt in treatment of goiter and cretinism. He introduced treatment of progressive paralysis with malaria, for what he got Nobel Price in 1928. He used Faradization therapy for war neurosis treatment.

Currency treatment is described as Middle Aged agony which should return back injured soldiers back to service, without treatment. This special institution was consisted of people without medical knowledge. They needed expert's testimony on currency treatment. That task was assigned to Dr. Sigmund Freud. Freud's testimony and defense of Wagner von Jauregg, are very informative about the way war neurosis were considered in those days (Eissler, 1986.). Freud stated, in 1920 that every neurosis has it's goal. Under his opinion, all war neurosis are subconscious run in sickness, away from the war. Freud finished his report with words: "However, war neuroses disappears with the end of war – and that is the last prove of psychological cause of their sickness."

Freud was to clever to criticize his famous colleague. He justified the treatment that Wagner von Jauregg was performing, although he preferred psychoanalysis. In his latter works, we see that he found out, like many others, that war neurosis do not disappear spontaneously after the end of war (Eissler, 1986).

Chronic, residual syndromes connected with battle and shell shock, became known as “war neurosis”. It was considered, in period between World Wars, that drawbacks, increased by battle experience, are result of predisposition or lack of personality. The result of that was neglectance of traumatic influence of war.

World War Two

During the World War Two many soldiers were also put out of order because of nerve break-down. Alliance forces had double bigger rate of dismission due to psychiatric losses, that in the World War One. The rate of coming back to battlefield was lower too (Appels et al., 1946.). The Commander of American forces in Tunis, ordered to note all psychiatric disorders as exhaustion, no matter to manifestations. It looks like that this act was part of tactics, which should (because of savings) reduce battle influence on mental attenuation.

Tiredness, exhaustion, narrowness, psychosomatic symptoms were diagnosed. Only smaller part of these diagnoses were referred to conservative reactions. Disorders, such one noticed in World War One, were obviously less present (Neill, 1993). After the war, American Army founded special institution which task was to consider psychiatric politics and practice. It's members described: “The first signs of coming break-down are soreness and sleeping disorders combined with oversensitivity to the smallest outer irritations: that is the start of fear reaction. General psycho motor slowness, solitude, tendency to destroy needed equipment, loss of interest, enhanced fear, dependence on others appears in partial disorganization phase.” (Bartlemeier et al., 1946). They recommended the term combat exhaustion. Specially, large number of psychosomatic cases seen during the war was noted. Genetic factors were not mentioned in the report.

Combat exhaustion is understood as act of finiteness of human endurance to taught stresses. Several researches tried to find out factors that influence liability to combat exhaustion (Archibal and Tuddenham, 1965; Grinker and Spiegel, 1945.. Grinker and Spiegel found out that on Air force soldiers with diagnosed combat exhaustion, family neurosis, obsessive and compulsive personality characteristics and worse narrowness control can be determined (Grinker and Spiegel, 1945). Weinberg described connection between “combat neurosis” and childhood problems, but he also admitted that one part of normal and healthy soldiers also had combat neurosis (Weinberg, 1946.). Swank founded existence of personality disorders before joining army on 2000 soldiers with combat exhaustion (Swank, 1949). Disordered childhood and unsuccessful adaptedness before joining army, were diagnosed on 1500 veterans from the World War Two with psycho neurotic break-down (Brill and Beebe, 1949.). All these researches did not manage to define specific pre-morbid predispositions. Besides that, it was concluded that determinant factors are battle intensity and duration, and that (theoretically) every soldier is going to suffer from combat stress, if he is exposed long enough to taught battle. Grinker and Spiegel declared that "the main problem in all cases of combat neurosis is narrowness and how to control it" (Grinker and Spiegel, 1945.).

During the World War Two conversion reactions were not vanished, but they were significantly less frequent than in World War One. What is the explanation of main changes in psychological reactions of soldiers? How is it possible to change general picture in 30 years from conversion to exhaustion?

In the years between two World Wars, evolution in thinking about psychology and psychiatry possibilities happened. Psychoanalysis theory became more and more popular. People were reading books of Freud and his successors. Terms subconscious and suppression became part of everyday language. Non psychotic states were not experienced as act of bad constitution. They were considered as slight disorder, that is consequence of bad living experiences and unhappy childhood, and it was believed that they can be cured. By the end of century war was accepted as almost usual and necessary life aspect. Warrior was generally considered as high-spirited and brave person. Chronic physical invalidity caused by war was sign of style and produced respect. In centuries, duel for honor was consequence of real or unreal despite or umbrage. War was a kind of duel between nations.

In the years between two world wars, such picture changed. Unimaginable, cruel and meaningless massacre of World War One destroyed illusion about glorious war. Battle was more and more often considered as abnormal, collective loss of sense, superiority of human bestiality over sense and civilization. War was not accepted as adequate solution to international conflicts. Non tendency to war was not considered as act of weak and women, it became politically correct standpoint.

By the XIX century, battles were fought on battlefield. That changed during the World War One. Number of killed soldiers was almost equal to number of killed civilians in that war. War was not event that happened away from homes any more. Everyone became target in total war.

World War Two data can confirm this too. Compared to World War One, in this war number of killed civilians was twice bigger than number of killed soldiers.

In the past, death and physical injuries were only acceptable cause for not taking a part in battle. Injured and exhausted soldiers in ditches during 1914-1918 had all symptoms of brain damage (tremble, pseudo-epileptic attack, loss of sight, hearing and memory). During the World War Two, disabling tiredness as consequence of hard efforts and tension, was accepted as common human reaction, and it was confirmed by medical experts. We can conclude that socio-cultural context has the biggest influence on exposing fatigues connected with war stress. In parallel with social revolution, clinical manifestations and war neurosis assessment changed too.

In one recent research about reactions caused by battles (in the last 120 years, since American Civil War to Vietnam War), Smith proves that, historically speaking, reactions on heavy stress were focused on cause and on individual differences between events: "If we take into account predispositions and situations, the key question is which one is guilty." (Smith,1981.).

Social and cultural norms and values are reflected in laws and formal canons. All European countries have laws about incapable war veterans. They have right on indemnification in the case of permanent incapableness, if it started during the military service. These laws give interesting information about medical theories and their interpretation of mental disorders caused by war stress

In period after the World War One, in Germany, war neurosis were considered as social sickness, that was based on genetic predisposition. Leading psychiatrists claimed that war neurosis were caused by secondary profit, and that they were products of social assurance system: "The law is the cause of traumatic neurosis (das Gesetz ist die Ursache der Unfallsneurosen)" (Van der Kolk et al., 1996). All war neurosis were considered as rent neurosis. In Germany, legal act about social assurance (Reichsversicherungsordnung) from 1926. reinforced this standpoint (Van der Kolk et al., 1996). Indemnification could not be got for traumatic neurosis. Behind this politics was opinion that traumatic neurosis can not be cured if one receives rent for it.

Development of the term PTSD

During the Korean War, USA army had politics of spending at most 9 months in the battle. That was based on known facts about combat exhaustion. The consequence of such politics, was low rate of psychological losses caused directly by battle (Figley, 1978).

The first Diagnostic and Statistical Handbook for Mental Disorders was printed during the Korean War (DSM I., 1952). This handbook defined ”heavy stress reactions” as situations where one is exposed to exceptional physical demands or extreme emotional stress, including battle. In the second, modified edition of handbook, term of heavy stress reaction was skipped. Stress caused by battle is mentioned only as short interpretation under title “Adaptation Reactions of Adults”. It is described as “fear connected with battle, which is manifested as tremble, running away and hiding” (DSM II., 1968).

We needed one more war to learn that people can be damaged by battle for life. That was the Vietnam War. The third edition of notebook (DSM III., 1980.) included the most recent researches and clinical analysis of USA Vietnam veterans adaptation problem. New diagnostic category was introduced: post traumatic stress disorder (PTSD; American Psychiatric Association, 1980.). This state is characterized by 3 sets of symptoms:

  • Unwanted, painful and disturbing repeated experience of the traumatic event, which appears as flashback or nightmares.
  • Trying to avoid situations that remind on traumatic events. That leads to emotional insensitiveness and social isolation.
  • Signs of hyperactivity, like hyper-excitableness, overreactions like fear and insomnia.

 

These symptoms are not specific to war veterans only. PTSD can be developed on victims of other kinds of psychological violence too. Disorder is noticed on people that survived natural disasters, criminal violence, political exile, abduction, sexual attack and harder misfortune

Main elements of PTSD were described in 1941 by A. Kardiner. His book “War Traumatic Neurosis” contains his observations during treatment of World War One veterans that suffered from chronic war neurosis. He noticed that people that suffer from pathological traumatic syndrome act like traumatic situation (that caused reaction) still exists. It was manifested by obsession with trauma, shifted uptake of own personality, atypical dreams, soreness, aggression attacks and reactions of over haggardness. Kardiner indicated that symptoms are consequence of the state. He treated traumatic reaction like “physioneurosis”, because the symptoms were psychological and physiological. Kardiner claimed that war neurosis could be the most often psychiatric diagnosis in the world (Kardiner, 1947).

The term PTSD became accepted and recognized in surprisingly short period. It is revealed in National Vietnam Veterans Readjustment Study that 20 years after the war, about 15,2 percent of male, veterans of war suffered from PTSD, while 11,1 percent suffered from partial PTSD (Kulka et al., 1990).

Departments for mental health in the West, officially recognized late consequence of traumatic experiences as disorder. That brought, for now, silence in discussions about origins of post-traumatic manifestations.

Comment

Old terms hysteria, war neurosis, traumatic neurosis, chronic reactive depressions and post-concentration camp syndrome are replaced with post traumatic stress disorder in modern literature. PTSD is interpreted as consequence of psychological trauma which is caused by psychological mechanisms like over-narrowness and dissociation. The only cause is traumatic experience.

Should we conclude that psychiatrists in the past had shifted sense for reality, and were wrong when believing in simulation and lust to neurosis development? That would be oversimplified. There are enough scientific proofs that pre-morbid neurotic development or genetic insensitiveness are not necessary conditions for PTSD development. Anyway, there are enough clinical proofs that some people develop serious PTSD after minor traumatic event. In such cases, pre-morbid factors like limited narrowness tolerance, often play hidden but important role. The question, why in some cases PTSD becomes chronic and exhaustive illness, while in some cases symptoms gradually disappear (although they were caused by similar events), can not be answered, if factors like neurotic profit, genetic sensitiveness, co-morbid psychiatric disorders or personality disorders are not taken in account. Simplification of these very complex inter reactions does not help. The truth in one case, does not have to be truth in all cases. We need specific and detail information in order to replace generalization with balanced and good documented theory.

Epidemiological researches have it's limitations. Researches of groups of people using psychometric instruments are important in order to analyze very complex reactions, like earlier life experience and trauma sensitiveness. As example, unhappy childhood can make some people sensitive to future events, while it can develop some sort of resistance on others. Further, comparing two groups of people (with happy and unhappy childhood) can indicate that both groups are equally liable to latter trauma. In groups, of people that had taught youth, sensitive and insensitive people can “neutralize” each other. Man is willing to conclude that childhood experience does not matter in such things.

Social development on the West, in the last hundred years radically changed clinical picture and official valuation of traumatic stress. Social development is still in progress. What is the future of development?

Chinese alphabet is completely different when compared to West alphabet. It is not based on sound illustration, it is based on image illustration. Those images represent objects, facts, emotions and abstractions. Chinese sign for trauma is Wei Chi.

The first sign represents person on the rock, in dangerous position, trying to keep the balance. This sign represents danger. The main sense of the second sign is capability or opportunity. By that trauma=danger+opportunity. It recognizes two aspects of trauma, the one that is connected with threat and danger, and the one that is connected with opportunity (progress capability). In the last years, in research of traumatic consequences, western part of the world paid great attention on narrowness aspect. We neglected opportunity aspect. Surviving of deterrent, shocking and degrading event has two aspects. Humans have imposing ability of psychological recoverability. Social support like, respecting of experienced suffering, understanding and respect of other people, getting opportunity to express own feelings (positive and negative) can help in development of new and better “I”, even at people with very deep and hard psychological injuries.

Diagnosis of PRSD is revelation and also a sign. Traumatic experiences are followed by complex serial of positive and negative transformations. The order of these changes significantly differences from one person to another.

In this paper, long term effects of exposure to traumatic stress are presented. It leads to chronic inability and intensive suffering in most cases. In that aspect, from medical point of view, veterans with battle experience are jeopardized group. They need special treatment and care after releasing from the army. They need constant controls of physical and psychical health, and quick intervention and treatment if stress symptoms arise. My recommendation is establishing of institutions for such tasks in every country. I frankly hope that World Veterans Organization is going to work on that task.

Literature

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