U.S. troops returning home: Are you prepared?
Their psychiatric problems go beyond posttraumatic stress because of unique combat in Iraq and Afghanistan.
PTSD in combat veterans
Every war has seen new names and descriptions for combinations of psychological and somatic symptoms resulting from war experiences (Box).9,11 Compared with persons with PTSD from other types of trauma, combat veterans appear to have the highest rate of delayed-onset PTSD and are less responsive to treatment.9
Initial PTSD rates for soldiers returning from Iraq ranged from 12.2% (Marines) to 12.9% (Army), using diagnostic criteria requiring functional impairment.7 These rates are 2.5 times the rate observed before combat (5%) and 3 to 4 times that of the general population (3.6%), using the same methodology.10
If 12.5% of 1 million combat-exposed service members develop PTSD, 125,000 service members may be affected. This rough estimate—7 times the number of personnel officially reported as “wounded”—does not take into account the wide variability of combat exposure among deployed troops or the effects of combat stress interventions (which might decrease the rate). Nor does it consider the impact of multiple rotations and possible decreased combat simulation training in reserve troops (which might increase the rate).
During the Civil War, soldiers with pathologic reactions to combat were described as having “irritable heart” or “soldier’s heart.”9 Since then, every war has seen new names and descriptions for combinations of psychological and somatic symptoms resulting from war experiences.
Affected troops in World War I were said to have “shell shock,” whereas those in World War II and the Korean War had “combat fatigue.” Those fighting in the jungles of Vietnam had posttraumatic stress disorder (PTSD).
Along with evolving psychiatric nomenclature and diagnostic schema, each war—including those in Iraq and Afghanistan—has had unique symptom constellations.11 These differences relate to the contemporary state of scientific and medical knowledge, sociocultural factors, and popular press concerns. Some differences stem from actual or perceived weapon effects (such as chemical warfare or depleted uranium).
For example, World War I physicians at first considered “shell shock” to result from traumatic effects of high-explosive shells on the brain. This explanation proved inadequate when soldiers without direct concussive exposure expressed trauma-related symptoms.12
To develop, PTSD requires synergy between a severe stressor and a neurobiologic response. Because of genetic endowment or experience, not all persons are susceptible to the high levels of stress and associated hypothalamus-pituitary-adrenal axis activation required for the disorder to occur. Specific individual differences in coping, trauma history, and biology may predispose some individuals to PTSD.11
Mr. L’s story: Detached and irritable
As a combat infantryman, Mr. L was in seven fire fights, in which three of his buddies died. In responding to your questions, he admits feeling disconnected from his children and from his old friends who did not go to Iraq. He describes frequent arguments with his wife, though they had rarely argued previously. He denies psychiatric problems before his 12-month rotation in Iraq.
Being wounded in combat, surviving multiple life-threatening events, and experiencing combat of greater intensity and duration all increase the risk of developing PTSD. Mr. L’s multiple fire fights, loss of three friends, and other combat experiences place him at high risk for developing PTSD.
Typical combat experiences in Iraq and Afghanistan reported by Army and Marine troops are outlined in Table 3.7 Familiarizing yourself with these experiences can help you interview combat-exposed patients after you develop trust and rapport with them.
Table 3
Combat experiences reported by U.S. troops
after deployment in Iraq or Afghanistan
| Experience | Army groups | Marine group | |
|---|---|---|---|
| Afghanistan | Iraq | ||
| Being attacked or ambushed | 58% | 89% | 95% |
| Receiving incoming artillery, rocket or mortar fire | 84% | 86% | 92% |
| Being shot at or receiving small-arms fire | 66% | 93% | 97% |
| Shooting or directing fire at the enemy | 27% | 77% | 87% |
| Being responsible for death of an enemy combatant | 12% | 48% | 65% |
| Being responsible for death of a noncombatant | 1% | 14% | 28% |
| Seeing dead bodies or human remains | 39% | 95% | 94% |
| Seeing dead or seriously injured Americans | 30% | 65% | 75% |
| Knowing someone seriously injured or killed | 43% | 86% | 87% |
| Participating in demining operations | 16% | 38% | 34% |
| Seeing ill or injured women or children whom you were unable to help | 46% | 69% | 83% |
| Being wounded or injured | 5% | 14% | 9% |
| Being shot or hit, but protective gear saved you | * | 8% | 10% |
| Having a buddy who was near you shot or hit | * | 22% | 26% |
| Clearing or searching homes or buildings | 57% | 80% | 86% |
| Engaging in hand-to-hand combat | 3% | 22% | 9% |
| Saved the life of a soldier or civilian | 6% | 21% | 19% |
| * Question not included in this survey | |||
| Source: Adapted and reprinted with permission from Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004; 351:13-22. | |||
