The Battle Over Battle Fatigue

Military history is rich with tales of warriors who return from battle with the horrors of war still raging in their heads. One of the earliest known observations was made by the Greek historian Herodotus, who described an Athenian warrior struck blind "without blow of sword or dart" when a soldier standing next to him was killed. The classic term--"shell shock"--dates to World War I; "battle fatigue," "combat exhaustion" and "war stress" were used in Word War II.

Modern psychiatry calls these invisible wounds post-traumatic stress disorder. And along with this diagnosis, which became widely known in the wake of the Vietnam War, has come a new sensitivity to the causes and consequences of being afflicted with it.

Veterans with unrelenting PTSD can receive disability benefits from the Department of Veterans Affairs. As retired Army Gen. Eric K. Shinseki, secretary of Veterans Affairs, said last week, the mental injuries of war "can be as debilitating as any physical battlefield trauma." The occasion for his remark was a new VA rule allowing veterans to receive disability benefits for PTSD if, as non-combatants, they had good reason to fear hostile activity, such as firefights or explosions. In other words, veterans can now file a benefits claim for being traumatized by events they did not actually experience.

The very notion that one can sustain an enduring mental disorder based on anxious anticipation of a traumatic event that never materializes is a radical departure from the clinical--and common-sense--understanding that disabling stress disorders are caused by traumatic events that actually do happen to people. This is not the first time that controversy has swirled around the diagnosis of PTSD.

In brief, the symptoms of PTSD fall into three categories: re-experiencing (e.g., relentless nightmares; unbidden waking images; flashbacks); hyper-arousal (e.g., enhanced startle, anxiety, sleeplessness); and phobias (e.g., fear of driving after having been in a crash). Symptoms must last at least one month and impair the normal functioning to some degree. Overwhelming calamity, not only combat exposure, can lead to PTSD, including natural disasters, rape, accidents and assault.

Not everyone who confronts horrific circumstances develops PTSD. Among the survivors of the Oklahoma City bombing, 34% developed PTSD, according to a study by psychiatric epidemiologist Carol North. After a car accident or natural disaster, fewer than 10% of victims are affected, while among rape victims, well over half are affected. The reassuring news is that, as with grief and other emotional reactions to painful events, most sufferers get better with time, though periodic nightmares and easy startling may linger for additional months or even years.

Rather than broaden the definition of PTSD, it would do our veterans better to ensure they first receive quality treatment and rehabilitation before applying for disability status.

Large-scale data on veterans are harder to come by. According to the major study of Vietnam veterans, the 1988 National Vietnam Veterans' Readjustment Study, 50% of those whose stress reactions were diagnosed as PTSD recovered fully over time. A re-analysis of the data, published in Science in 2006, found that 18.7% of Vietnam veterans suffered PTSD at some point after returning from war, but half had recovered by the time the study was conducted in the mid-1980s.

A 2010 article in the Journal of Traumatic Stress summarized over two dozen studies and found that among servicemen and women previously deployed to Iraq and Afghanistan, between 5% and 20% have been diagnosed with PTSD.

The story of PTSD starts with the Vietnam War. In the late 1960s, a band of self-described antiwar psychiatrists--led by Chaim Shatan and Robert Jay Lifton, who was well known for his work on the psychological damage wrought by Hiroshima--formulated a new diagnostic concept to describe the psychological wounds that the veterans sustained in the war. They called it "Post-Vietnam Syndrome," a disorder marked by "growing apathy, cynicism, alienation, depression, mistrust, and expectation of betrayal as well as an inability to concentrate, insomnia, nightmares, restlessness, uprootedness, and impatience with almost any job or course of study." Not uncommonly, Messrs. Shatan and Lifton said, the symptoms did not emerge until months or years after the veterans returned home.

This vision inspired portrayals of the Vietnam veteran as the kind of "walking time bomb" as immortalized in films such as "Taxi Driver" and "Rambo." In the summer of 1972, the New York Times ran a front-page story on Post-Vietnam Syndrome. It reported that 50% of all Vietnam veterans--not just combat veterans--needed professional help to readjust, and contained phrases such as "psychiatric casualty," "emotionally disturbed" and "men with damaged brains." By contrast, veterans of World War II were heralded as heroes. They fought in a popular war, a vital distinction in understanding how veterans and the public give meaning to their wartime hardships and sacrifice.

Psychological casualties are as old as war itself, but historians and sociologists note that the high-profile involvement of civilian psychiatrists in the wake of the Vietnam War set those returning soldiers apart. "The suggestion or outright assertion was that Vietnam veterans have been unique in American history for their psychiatric problems," writes the historian Eric T. Dean Jr. in "Shook over Hell: Post-Traumatic Stress, Vietnam, and the Civil War." As the image of the psychologically injured veteran took root in the national conscience, the psychiatric profession debated the wisdom of giving him his own diagnosis.

During the Civil War, some soldiers were said to suffer "irritable heart" or "Da Costa's Syndrome"--a condition marked by shortness of breath, chest discomfort and pounding palpitations that doctors could not attribute to a medical cause. In World War I, the condition became known as "shell shock" and was characterized as a mental problem. The inability to cope was believed to reflect personal weakness--an underlying genetic or psychological vulnerability; combat itself, no matter how intense, was deemed little more than a precipitating factor. Otherwise well-adjusted individuals were believed to be at small risk of suffering more than a transient stress reaction once they were removed from the front.

In 1917, the British neuroanatomist Grafton Elliot Smith and the psychologist Tom Pear challenged this view, attributing the cause more to the experiences and less on those who suffered them. "Psychoneurosis may be produced in almost anyone if only his environment be made 'difficult' enough for him," they wrote in their book "Shell Shock and Its Lessons." This triggered a feisty debate within British military psychiatry, and eventually the two sides came to agree that both the soldier's predisposition to stress and his exposure to hostilities contributed to breakdown. By World War II, then, military psychiatrists believed that even the bravest and fittest soldier could endure only so much. "Every man has his breaking point," as the saying went.

In 1980, the American Psychiatric Association adopted post-traumatic stress disorder (rather than the narrower Post-Vietnam Syndrome) as an official diagnosis in the third edition of its Diagnostic and Statistical Manual.

A patient could be diagnosed with PTSD if he experienced a trauma or "stressor" that, as DSM described it, would "evoke significant symptoms of distress in almost everyone." Rape, combat, torture and fires were those deemed to fall, as the DSM III required, "generally outside the range of usual human experience." Thus, while the stress was unusual, the development of PTSD in its wake was not.

No longer were prolonged traumatic reactions viewed as a reflection of constitutional vulnerability. They became instead a natural process of adaptation to extreme stress. The influence of individual differences shaping response to crisis gave way to the profound impact of the trauma, with its leveling effect on all human response.

If the pendulum swung too far, obliterating the role of an individual's own characteristics in the development of the condition, it served a political purpose. As British psychiatrist Derek Summerfield put it, the newly minted diagnosis of PTSD "was meant to shift the focus of attention from the details of a soldier's background and psyche to the fundamentally traumatic nature of war."

Messrs. Shatan and Lifton clearly saw PTSD as a normal response. "The placement of post-traumatic stress disorder in [the DSM] allows us to see the policies of diagnosis and disease in an especially clear light," writes combat veteran and sociologist Wilbur Scott in his detailed 1993 account "The Politics of Readjustment: Vietnam Veterans Since the War." PTSD is in DSM, Mr. Scott writes, "because a core of psychiatrists and Vietnam veterans worked conscientiously and deliberately for years to put it there . . . at issue was the question of what constitutes a normal reaction or experience of soldiers to combat." Thus, by the time PTSD was incorporated into the official psychiatric lexicon, it bore a hybrid legacy--part political artifact of the antiwar movement, part legitimate diagnosis.

While the major symptoms of PTSD are fairly straightforward--re-experiencing, anxiety and avoidance--what counted as a traumatic experience turned out to be a moving target in subsequent editions of the DSM.

In 1987, the DSM III was revised to expand the definition of a traumatic experience. The concept of stressor now included a secondhand experience. In the fourth edition in 1994, the range of "traumatic" events was expanded to include hearing about the unexpected death of a loved one or receiving a fatal diagnosis such as terminal cancer. No longer did one need to experience a life-threatening situation directly or be a close witness to a ghastly accident or atrocity. Experiencing "intense fear, helplessness, or horror" after watching the Sept. 11 terrorist attacks on television, for example, could qualify an individual for PTSD.

There is pitched debate among trauma experts as to whether a stressor should be defined as whatever traumatizes a person. True, a person might feel "traumatized" by, say, a minor car accident--but to say that a fender-bender counts as trauma alongside such horrors as concentration camps, rape or the Bataan Death March is to dilute the concept. "A great deal rides on how we define the concept of traumatic stressor, says Harvard psychologist Richard J. McNally, author of "Remembering Trauma." In the civilian realm, Mr. McNally says, "the more we broaden the category of traumatic stressors, the less credibly we can assign causal significance to a given stressor itself and the more weight we must place on personal vulnerability."

For some non-combat servicemen and women, anticipatory fear of being in harm's way can turn into a crippling stress reaction. But how often symptoms fail to dissipate after separation from the military and subsequently morph into a lasting disability is unknown.

Americans are deeply moved by the men and women who fight our wars. We have an incalculable moral debt, as Abraham Lincoln said, "to care for him who shall have borne the battle." Yet rather than broaden the definition of PTSD, it would do our veterans better to ensure they first receive quality treatment and rehabilitation before applying for disability status. Otherwise, how can we assess their prospects for meaningful recovery no matter their diagnosis?

The new regulations announced by Mr. Shinseki take the definition of PTSD further than any of his predecessors surely imagined.

Sally Satel is a resident scholar at AEI.

Photo credit: U.S. Army/Department of Defense

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