January 26, 2009 – For the Ancient Greeks, it was a “divine madness” that infected the minds of soldiers. During the US Civil War, it became known as “soldier’s heart”. By the First World War it was called shell shock. Today, the condition is known as Post-Traumatic Stress Disorder.
The idea that war can inflict deep and lasting psychological wounds is not new. In Sophocles’s tragedies, former soldiers descend into a state of mind that would be all too familiar to modern military psychiatrists. Yet despite the passage of more than 2,400 years, our understanding of PTSD has remained surprisingly unsophisticated: not only are the underlying biological and psychological causes poorly understood, but it is almost impossible to predict which soldiers are the most susceptible.
Now, however, new research from America – triggered by the soaring incidence of PTSD among troops returning from Iraq and Afghanistan – has found striking differences in the brain patterns of those suffering from combat stress, raising hopes that we will be able to identify and treat sufferers much more effectively.
At the most basic level, PTSD is the result of a breakdown in the defence system that copes with traumatic and frightening experiences. After such events, most people will suffer what is known as Acute Stress Disorder, which involves symptoms of anxiety and depression. The majority will recover, but a minority go on to develop the chronic mental health problems that characterise PTSD.
“They get stuck in a cycle whereby recollections of a traumatic event are triggered by a particular situation they encounter,” explains Professor Simon Wessely, director of the King’s Centre for Military Health Research at the Institute of Psychiatry, King’s College London. “This triggers the symptoms, and they then try to avoid the situation that triggered the recollections – but that just means that the symptoms get worse the next time they encounter the same situation.”
“Those who develop PTSD are not necessarily the most vulnerable,” adds Professor Roberto Rona, a lecturer at King’s Psychological Medicine and Psychiatry Division. “Ideally, we would want to start treatment as soon as possible by separating those who are going to recover normally and those who will have a problem after a traumatic event.”
One way to find them might be to scan the brains of those affected. In 2007, as fighting intensified in Afghanistan and Iraq, cases of PTSD among American military personnel increased by more than 50 per cent. The Pentagon poured money into research – the latest instalment of which has revealed that there are differences in parts of the brains of those with PTSD.
Older studies had linked PTSD to changes in the activity of the amygdala, the area of the brain involved in emotional memory. But Dr Norbert Schuff, of the Veterans Affairs Medical Centre in San Francisco, found using MRI scans that the hippocampus of sufferers, which plays a major role in short-term memory and emotions, had decreased in size. There was also increased blood flow in the prefrontal cortex, the region responsible for decision-making – hyperactivity here is thought to be involved in the excessive reaction to fear. Most strikingly, there was a loss of up to 10 per cent of the grey matter – the nerve cells and blood vessels that make up much of the brain.
What is unclear is exactly why these changes have come about – and whether they are the cause of combat stress, or its consequence. “It is hard to say which comes first,” explains Professor Wessely. “Do the changes in the brain cause the symptoms? Or do they occur as an effect of prolonged stress – or is it a result of alcohol abuse or head injuries?”
One possible explanation comes from research which found a link between PTSD and mild brain trauma, suggesting that the condition could in some cases be triggered by mild brain injuries resulting from nearby explosions. But there is another curious piece of the puzzle. While cases of PTSD are common outside the Armed Forces, soldiers should be particularly vulnerable: their jobs place them in frightening situations where they are more likely to encounter the kind of events that can spark psychological problems.
But while around 20 per cent of ex-combatants in the British Armed Forces do suffer some sort of psychological disturbance – hence the need for the work of Combat Stress, one of the three charities involved in the Telegraph’s annual appeal, which ends this week – PTSD is only one of a number of conditions. According to official figures – which some campaigners dispute – just 3 per cent of the British troops sent to Iraq or Afghanistan on active duty develop PTSD. The single biggest mental health problem is alcoholism: according to recent studies, 27 per cent of soldiers are heavy drinkers, and 15 per cent are problem drinkers.
This does not make PTSD any less of a problem. Sufferers are plagued with recurring nightmares, insomnia and depression, experiencing high anxiety, mood swings and relationship difficulties. Divorces, unemployment, homelessness and violence become common; vivid flashbacks can lead to panic attacks; and veterans often sink into a cycle of alcohol or drug abuse as they attempt to deal with their symptoms.
But Prof Wessely has found that the very thing that exposes soldiers to PTSD might also help them deal with it: their job. According to his research at King’s, group cohesion and firm leadership are critical in reducing the impact of psychological distress.
“You have to remember we are talking about professional soldiers who have been highly trained,” he says. “Their training is designed to harden them against the unpleasant nature of war. The military is actually very effective at reducing the risk of PTSD with their training, their professionalism, esprit de corps and morale. War is a stressful business and this all prepares soldiers for that.”
The flip side is that the memories that provoke trauma are not necessarily those of gruesome battles or injuries. “The kind of events that affect them are not simply seeing bad things and coming under fire – it is when the rules they have come to expect are somehow broken. It is when errors of omission or commission lead to the feeling they have been let down, or that they have let their comrades down, that mental health problems occur. This is why ‘friendly fire’ incidents are so psychologically damaging – it violates the soldiers’ rules of who is supposed to be shooting at them. They will feel anger at those responsible.”
That was certainly the case for James Saunders, a veteran of the Gulf War interviewed by The Daily Telegraph last month. As a 21-year-old in the Royal Artillery, he experienced “friendly fire” from Challenger tanks. No one was killed, but six months later he began to suffer from anxiety and depression, developed a drug habit and ended up in prison. “For years,” he says, “I blamed myself for being a poor soldier and weak-minded.” Having sought help from Combat Stress, and been diagnosed with PTSD, Saunders recovered, although he still suffers from occasional depression. On Thursday, he will speak about his battle against PTSD alongside Professor Wessely at the Dana Centre in London.
In addition to the research into the causes of PTSD, new treatment is being developed, drawing on neurolinguistic programming, relaxation techniques and even Eye Movement Desensitisation Therapy, which involves following a moving light or object with the eyes, to work through the bad memories. But there are no simple solutions.
“I don’t think there are many people who believe PTSD will be solved by simply giving people a drug,” says Wessely. “With soldiers, the only really effective way of preventing it would be to not go to war in the first place.”