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The myth and reality of Post Traumatic Stress Disorder.

This post follows the film I made for Talking2Minds (see previous post). Above is a portrait of Britain's most famous General, Wellington, by Spanish artist Goya. The painting depicts the victorious Wellington on his entry to Madrid, but it is not this painting but Goya's chalk sketch that preceded it, shown below, that is of interest here. 
Here Wellington shows the signs of battle fatigue, or depression, that he suffered post combat. This was first documented after Assaye, India 1803, of which he wrote 'I should not like to see again so great a loss...even if attended by such a gain' and his biographer Elizabeth Longford refers to his waking after this with a recurrent nightmare about his troops, 'a confused notion that they were all killed'.
Napoleonic warfare was brutal but it did not compare to the carnage unleashed in the First World War, which brought with it the medical profession's interest in men who showed no physical wounds, but seemed ill. The footage of a shell shock victim from the Imperial War Museum never cease to shock me.
Counterintuitively modern psychiatry repeatedly states that post traumatic stress disorder (PTSD) occurs at the same rate amongst the civilian and military population, around 15 - 20%. One of the largest studies in this area by the British Journal of Psychiatry (PJPsych) goes on to say repeated combat tours do not increase this rate.
This does not concur with my own, albeit anecdotal, experience in this area and I think this is because there are two problems. The first is diagnostic. The psychiatric bar to a clinical PTSD diagnosis is set very high, to the extent that I now know personally of three people who have sought help and been refused. I would say this to the medical profession: if a soldier comes asking for help then he or she is in trouble. Soldiers learn to suffer without complaining, and if they are asking for help this means they do need it. Mental health is a spectrum, and the impact of combat on mental health ranges from mild depression, all the way up to what a psychiatrist will term PTSD, and may vary over time. Setting the bar high might keep the numbers down officially, but does not define the problem.
The second thing struck me reading the PJPsych article, and that is that the sample group is all troops, regardless of their role. In modern warfare the ratio of support troops to frontline is roughly 10 to 1, and while deploying in a support role to, say, Camp Bastion, Afghanistan, in the recent British involvement there, might be stressful, it would be unlikely to provoke a mental stress reaction other than boredom.  So this study could also be saying that 100% of those in combat roles suffer from PTSD, since 15% showing symptoms concurs with 15% being in combat. We don't know because they did not define the roles of those they were sampling.
Again, my own experience, I do not think this is true either: not all troops in combat suffer PTSD. I suspect that one of the defining factors in mental health in combat is casualties, both your own, and civilian. One of the most decorated Regiments in the British Army is the Royal Army Medical Corps and medics seem to suffer a high level of PTSD . And the impact of civilian casualties could be significant because as a soldier you sign up for the risk, and you are prepared mentally, but soldiers are often shocked by the carnage inflicted on the civilian population. This has increased in our modern wars 'amongst the people', and can even occur away from the frontline for example amongst troops deployed on peacekeeping duties.
Finally I would add that PTSD can take time to appear, again from experience around five to six years after combat, and that leaving the military seems to have an enormous impact on this process. The military is a family, and the double wrench of leaving the military is also leaving the support network that helped deal with, and mask, mental issues. 
My conclusion is there needs to be more research into PTSD, over longer periods, with sample groups defined both by role and exposure to risk factors. That group exists in the UK after recent conflicts. Critically, we need to ask who is doing the research. Combat Stress, the UKs largest veteran mental health charity is part funded by the Ministry of Defence (MOD). A military psychiatrist (not with Combat Stress) recently said alcoholism is to blame rather than mental illness among most veterans with mental problems, though alcohol misuse is a key symptom of this illness. We cannot blame those paid by the MOD for seeking different explantions since the MOD remit is to protect the country, and to do this they need to recruit young and men women, not fund more substantial research in an area that may ultimately affect recruitment.
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