To Hell and Back: Evolution of Combat-Related Post Traumatic Stress Disorder

Nidiffer, F. Don, Leach, Spencer, Developments in Mental Health Law

Abstract

Post Traumatic Stress Disorder (PTSD) is the psychiatric diagnosis now given to a set of reactive symptoms that result from experiencing a traumatic event or a series of such events. This Article will focus on the history of combat-related PTSD and the emotional and behavioral responses to being in a war zone. The history of this diagnosis will be reviewed in conjunction with related contemporary political, legal, and social developments to better understand the unique aspects of this diagnosis. The behaviors of military service members (i.e., Soldiers, Marines, Airmen, Sailors, and members of the Coast Guard) in combat and their integration back into society will also be addressed. Finally, the challenge of making reliable and accurate related diagnoses and determining the appropriate dispositions for Veterans with this disorder, including those who have run afoul of the criminal justice system, will also be briefly discussed.

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"It's my nerves. I can hear the shells come over but I can't hear them burst." (1)

I. Introduction

The quotation that begins this Article is arguably the most famous sentence uttered in the history of the military--and perhaps in general--regarding PTSD. Although reports vary, on August 3, 1943, Lt. Gen. George S. Patton, commander of the Seventh U.S. Army, was visiting a military hospital in Sicily. In one account (Finding Dulcinea, 2009), as Patton walked past the beds of wounded soldiers, he would ask them about their injuries. When he came to the bed of 18-year-old Pvt. Charles H. Kuhl, he noted no visible signs of injury. Patton inquired about Kuhl's health and was told he had been tentatively diagnosed as having a case of psychoneurosis.

Turning to Pvt. Kuhl, when Kuhl told Gen. Patton that he could not handle psychologically the battle lines, Patton reportedly became enraged, called Kuhl a coward, and slapped him across the face. As Patton began to leave the tent, he heard Kuhl crying. Turning back, he struck Kuhl again and ordered him to leave the infirmary tent. It later emerged that Kuhl had malaria and a high fever. In a less publicized event a week later, Patton slapped Pvt. Paul G. Bennet, who had been hospitalized for his "nerves." News of both incidents ultimately reached Gen. Dwight D. Eisenhower, who sent a letter of reprimand to Patton and wrote "I am well aware of the necessity for hardness and toughness on the battle field.... But this does not excuse ... abuse of the 'sick'."

Months later a radio broadcaster revealed to his American listening audience that Patton had slapped Kuhl, which resulted in many members of Congress and the press calling for Patton's removal from command. Notwithstanding that Patton at the time was one of the most famous and successful generals of World War II, the Senate delayed Patton's confirmation as major general because of this incident and he was relieved of his command of the Seventh Army by Eisenhower. Later he would be given command of the Third Army, which he led to victory in the Battle of the Bulge and other encounters. The repercussions Patton incurred for his response to these soldiers marked a significant shift in society's (and the military's) recognition of and response to PTSD.

PTSD has formally existed as a behavioral health issue since its inclusion in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III)in 1980. However, the symptoms associated with PTSD have no doubt always been part of human psychology. Emotional and behavioral reactions to traumatic life-threatening events have likely occurred since humans first hunted animals for food and competed with other humans for the resources needed for survival. On a more collective scale, warfare--which has been prominent throughout human history--has had a similar impact. Trauma has generally been an inherent component of this warfare, notwithstanding efforts by commanders of armies to sometimes ignore and, at other times, suppress what are relatively typical psychological and behavioral responses to life-threatening combat in their soldiers. Military and societal responses to military service members impaired by this trauma have varied based upon the perceived value of a given war and contemporary beliefs on how best to respond to this trauma. (See Table below).

As will be discussed, during the Revolutionary War, General George Washington managed a very fragile military structure, with many short-term enlistees and militia troops that were generally considered to be unreliable in combat. As a result, Washington feared contagion responses if soldiers did not stand and fight and so treated all related behaviors with equal harshness to prevent their spread. During the American Civil War, the first efforts to distinguish stress responses from cowardice, both medically and in terms of military punishment, were made. Soldiers who were unable to fight following a battle were sometimes viewed as suffering from a disease, which could merit discharge for psychiatric reasons rather than execution as a deserter. The concept of PTSD has continued to develop through the course of the many subsequent military conflicts, but organized treatments for PTSD-like symptoms have only been recently developed.

Fortunately, our understanding and treatment of PTSD have improved dramatically over the centuries (see Table below), particularly within the thirty years since the DSM-III was published. However, uncertainties remain regarding many aspects of the condition. Problems in diagnosis, assessment, and prevention, coupled with an increasing number of disputes regarding its relevance to the legal system, may undermine the rehabilitation of those who have fought in the service of their country. The following historical review will show the great strides that have been made in the treatment of military combatants suffering from PTSD, which can be attributed to both enhanced public understanding of the condition and medical advances. But greater advances are still needed to adequately honor those who labor in our defense.

II. The American Revolutionary War: General Washington's Views on Fight or Flight Responses

The American Revolutionary War (1775-1783) was one of the longest and most difficult conflicts in our nation's history. The thirteen rebelling colonies began the war with no standing army or navy and were pitted against the preeminent world power of the era, the British Empire. As the commander of the American armies during the war, General George Washington was required to build and maintain an effective fighting force composed of predominantly local militia, notorious for their lack of reliability in standing fast in the face of combat. High rates of desertion, low morale, and insufficient support from Congress (e.g., finances, supplies, etc.) only added to the near impossible task faced by Washington (Ward, 2006).

The hardships faced by the common soldier were similarly challenging, as they were almost always undersupplied, underfed, and unpaid, in addition to their harsh surroundings, like that faced at the winter camps such as Valley Forge. Soldiers were also often confronted with the dilemma of choosing between harvesting crops at home for the survival of their families and continuing their commitment to the war effort. Such conditions were ripe for the development of stress responses, especially when support networks and treatment were virtually non-existent.

Washington's focus was upon fielding the largest military force possible during the course of the war in a fledgling nation comprised of citizens split between those who wanted their independence from Britain and others who were "loyalists" (Tories) and who provided support to the occupying British forces, while burdened by the fact that nearly 25% of his soldiers deserted from their units. Confronted with so many obstacles, Washington felt a strong need to establish for potential deserters and "cowards" that facing the enemy was not nearly as perilous as what they would face if they did desert, which included not only a possible death penalty but also public humiliation for the soldier and his family.

Strict discipline was paramount in Washington's mind, and corporal punishment served as the primary mechanism of enforcing it. With emphasis on the pragmatic concern of maintaining units in the field, little effort was made to understand or respect reasons why a soldier might have other needs, such as returning home to support a family (e.g., to provide them with needed supplies and harvest crops) or dysfunctional reactions to combat. Behaviors and emotions resulting from combat stress were to be suppressed at all costs and without any consideration for treatment (Ward, 2006).

Soldiers suffering from combat stress or PTSD were not viewed differently from deserting or malingering soldiers and often faced the same brutal punishments that they did. Flogging was the primary method of punishment, but other penalties included running the gauntlet after shaving the offender's head and replacing his hair with tar and feathers. Other consequences included carrying a barrel over their shoulders, being shackled to a twenty to thirty pound log and dragging it along for days, being placed in a "cage," riding a wooden horse where nails created bodily injury, and a rare form known as "picketing" where the soldier was raised on an upright pole while their wrists were tied to a hook at the top and forced to balance themselves on a sharp peg. As the war progressed, the more brutal of these penalties were used infrequently, while serious military discipline infractions received primarily a various number of lashes (from 39 to 1000 depending upon a number of factors) or the death penalty, a punishment Washington had personally lobbied Virginia to allow in 1755 (with Washington issuing some 700 execution orders over the course of the war) (Ward, 2006).

The corporal and capital punishments imposed by the Continental Army were primarily intended to deter soldiers from emulating the punished soldier. Soldiers' fear of the pain and death inflicted by their own officers was believed to hold off what was viewed as the contagious effect of desertion. It is worth noting, however, that these severe punishments were ineffectual, failing to reduce rates of desertion from the army. Despite the extreme physical suffering involved and their minimal desired impact, Washington never moved to decrease the severity of the punishments for offenses (Ward, 2006).

Throughout the war, Washington never thought in terms of treating the symptoms associated with combat stress. His primary concern was to maintain the effective fighting force necessary to win the war, with the harsh governing of soldiers viewed as pragmatically necessary. The limited medical and psychiatric knowledge of the time only added to the predicament, for commanders had few ways to distinguish between cowards and soldiers with a psychiatric disorder, even if they had a desire to do so. It was only after the end of the war that Benjamin Rush, a physician of the period and a signer of the Declaration of Independence, became among the first to suggest that rehabilitation in some form would be better than mere punishment for dealing with men who did not want to fight due to what today would be classified as combat stress reactions (Ward, 2006). Rush's efforts to understand mental disorders and to promote humane treatment for those patients suffering from it set the foundation for American efforts to better respond to mental health needs and began the slow progression towards treating rather than scourging soldiers suffering the symptoms of PTSD (Hellemans & Bunch, 1988).

III. The American Civil War and the Concept of Illness

The American Civil War (1861-1865) was a deeply traumatic event for both the nation and the soldiers that …

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Publication information: Article title: To Hell and Back: Evolution of Combat-Related Post Traumatic Stress Disorder. Contributors: Nidiffer, F. Don - Author, Leach, Spencer - Author. Magazine title: Developments in Mental Health Law. Volume: 29. Issue: 1 Publication date: January 2010. Page number: 1+. © 2009 Institute of Law, Psychiatry & Public Policy. COPYRIGHT 2010 Gale Group.

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