The ongoing toll of war on soldiers' mental health

From The New York Times:

“Every man has his breaking point,” said military doctors in World War II, believing that more than 90 days of continuous combat could turn any soldier into a psychiatric casualty.

For Maj. Nidal Malik Hasan, the Army psychiatrist who military officials said gunned down dozens of soldiers at Fort Hood, Tex., on Thursday, that point may have come even before he experienced the reality of war; he was bound for a combat zone but had not yet embarked.

Major Hasan was being sent not to fight, but to join those ranks of doctors who, over centuries of war, have worried about breaking points — how much fear and tedium soldiers can take; how long they can slog through deserts or over mountains; how much blood they can see, how many comrades they can lose — and have sought ways to salve the troops’ psychic wounds and keep them fighting.

Much is unknown about Major Hasan’s motives. He is said to have dreaded deployment, but what he feared is unclear. And officials have not ruled out the possibility that his actions were premeditated or political. One report had him shouting something like “Allahu Akhbar” — Arabic for “God is Great” — before the shooting.

But even in this absence of certainty, his case invites a look at the long history of psychiatric medicine in war, if only because of his status as a battlefield psychiatrist, and the chance that his own psyche was, on some level, undone by the kind of stress he treated.

Over the centuries, soldiers have often broken under such stress, and in modern times each generation of psychiatrists has felt it was closer to understanding what makes soldiers break. But each generation has also been confounded by the unpredictability with which aggressions sometimes explode, in a fury no one sees coming.

The current wars in Iraq and Afghanistan have claimed more than their share of stress victims, with a rising number of suicides among soldiers and high rates of post-traumatic stress disorder. Such casualties often occur not on the battlefield but after it — or, sometimes, merely in its proximity.

In World War I, the disorder was known as shell shock, and the soldiers who fell victim were at first believed to have concussions from exploding munitions. Their symptoms appeared neurological: They included trembling, paralysis, a loss of sight or hearing.

Yet it turned out that some affected soldiers had been nowhere near an exploding shell, suggesting “that the syndrome could arise in anticipation of going into a stressful situation,” said Dr. Richard McNally, a professor of psychology at Harvard and an expert on traumatic stress.

Some doctors devised methods to treat shell shock victims — one German doctor tried electroshock to the limbs. But there was also widespread suspicions that the soldiers were malingering. Some soldiers were shot for cowardice.

Yet shell shock was simply the Great War’s version of a reaction to combat that has been detected even in the writings of antiquity. Achilles, Jonathan Shay maintains in “Achilles in Vietnam,” (Scribner, 1994) displayed a form of traumatic stress when in the Iliad he grieves over the death of his friend Patroclus.

Soldiers in the Civil War suffered from irritability, disturbed sleep, shortness of breath and depression, a syndrome Jacob Mendes Da Costa, an Army surgeon, described in 1871 as “irritable heart.”

In World War II, the paralysis and trembling of the early 1900s did not recur. But nightmares, startled reactions, anxiety and other symptoms persisted as “battle fatigue” or “war neurosis,” a condition whose treatment was heavily influenced by the rise of Freudian psychoanalysis.

Out of that war emerged a theory of battlefield treatment known as PIE, or proximity, immediacy and expectancy. The doctrine held that if a soldier broke down during combat, he should be treated close to the front, because if he was sent home, he would do poorly and seldom return to battle. Major Hasan, had he reached Iraq, would have practiced a similar approach: Soldiers are treated close to the forward lines and only removed to hospitals farther from the front in the most severe cases.

Today, the flashbacks, nightmares and other symptoms of soldiers are diagnosed as post-traumatic stress disorder or P.T.S.D., a term that replaced “post-Vietnam syndrome” and entered the official nomenclature in 1980, appearing in the American Psychiatric Association’s diagnostic manual. Like its predecessors, the disorder has been easier to diagnose than it has been to understand or to treat.

Research has yielded some treatments that studies show help soldiers, and the military — now acutely aware of the problem — has taken steps to make the methods widely available. Yet the history of treatments for combat stress has often been a circular one, with experts “remembering and forgetting and remembering and forgetting but never integrating and creating a lasting narrative that could be a blueprint for going forward,” as one psychiatrist put it.

Similarly, scientific views of what makes soldiers susceptible to stress disorders have waxed and waned. Some experts, in a modern echo of a view put forward in World War II, argue that soldiers who develop P.T.S.D. have longstanding vulnerabilities — psychological or physiological — that make them unable to withstand the pressures of combat. Others assert, in agreement with the military doctors of World War I, that every soldier simply has a breaking point, and that multiple deployments to Iraq and Afghanistan have contributed to the numbers who return to a second, psychological war at home.

Yet no theory seems able to capture the unpredictable effects of sustained violence on human beings, the subtle pressures that years of killing and more killing exert on a soldier, a doctor or a society — or the reality that every war travels home with the soldiers who fight it.

“All these people have been under a tremendous amount of stress,” said Dr. Stephen Sonnenberg, a psychiatrist and adjunct professor at the Uniformed Services University of the Health Sciences, speaking of soldiers and those who treat them. “They are holding the stress for everybody.”