MBChB, DipAvMed, MRNZCGP, MRAes
Warfare has always been stressful for its participants. Before the psychological impacts of the conflict in Afghanistan became apparent, our regular medical columnist looks at the history of post-war syndromes
For a very short-lived conflict the Gulf War has produced an enigmatic legacy of illness which has continued to produce wide-ranging theories as to the cause of what has become known as Gulf War Syndrome (GWS). My view is that GWS can best be understood by examining the history of ill-health both during and after warfare.
Disturbed behaviour during or after conflict was recorded during Greco-Roman times.
In 1678 the Swiss Physician Johannes Hofer described this behaviour in terms of a longing for home and family, and coined the term “nostalgia”.
By 1755 nostalgia was recognised as endemic. However, it did not prove a particularly severe problem in terms of casualties because battle fatigue and exhaustion were limited by the short time scale of early conflicts. For example, the Battle of Agincourt could be measured in a few hours and Waterloo was over in three days. Given such circumstances, it is easy to see that nostalgia was related to prolonged periods away from home rather than the stress of imminent conflict.
The American Civil War provided some useful records and during the first two years of the conflict nostalgia produced a casualty rate of 2-3 per thousand. The American Civil War was a conflict where the weaponry was greatly in advance of the tactics and this led troops to have a certain anxiety about the blast effects of artillery. This led to the concept of “windage”, where it was thought that the pressure wave of a passing shell could produce paralysis of one or more limbs. Two percent of the Union Army were discharged owing to such paralysis.
In 1866, Sir John Erichsen had introduced the concept of “railway spine”, the idea being that the shock of a railway accident could produce functional disturbances of memory and neurological function in the absence of any physical injury. No connection appears to have been made between this syndrome and windage injury in soldiers. Doctors were, however, trying to come up with a classification system for mental illness. The term “neurosis” had already been coined by William Cullen in the 18th century as a blanket expression for all nervous disorders. Later, George Beard introduced the concept of neurasthenia which sought to explain nervous symptoms through some physical exhaustion of the nerves.
By 1910, Professor Glynn, writing in the Lancet, concluded that an emotional disturbance “probably plays a more important part in the production of the traumatic neurosis than physical injury. ” It was therefore easy to describe at this time how experience of war could lead to a war neurosis.
During the Boer War, MOs were highly suspicious of functional disorders which were widely believed to be a manifestation of malingering. Psychological theory, moreover, was strongly influenced by class considerations.
Nevertheless, there was a high rate of discharge for insanity which was probably really a description of “shell-shock”, an expression originally coined by Charles S. Myers of the RAMC in 1915. About the same time, American Physician John T. MacCurdy described conversion hysteria where the stress of combat exposure led to the development of loss of speech, deafness and limb paralysis.
Belief in windage persisted during WW1 and soldiers believed that the percussion of a near miss could produce some mysterious changes in the nervous system capable of destroying their self control. This illness perception was subject to local interpretation; for example, German troops developed a Parkinsonian type of tremor while French troops developed limb paralyses as a result of conversion hysteria. British soldiers suffered from effort syndrome which was a psychosomatic condition producing shortness of breath.
Widespread concern
By 1915 there was widespread public concern at the diagnosis of shellshock, in particular the number of soldiers sent home with the label of insanity. Army GS did not accept the diagnosis of shellshock as a defence at Courts Martial for cowardice and desertion. This is not surprising when many MO’s held opinions like one anonymous RMO on the Western front: “If a man lets his comrades down he ought to be shot. If he’s a loony so much the better.”
In the opposing trenches the German Army held to similar views. War neurosis was initially seen as a violation of military discipline with underlying suspicion of malingering. In the best Teutonic tradition, treatment consisted of strict military discipline and electric shock treatment. By 1916 most German neurologists agreed that shell-shock was purely psychological and it was realised that the best treatment was rest with the expectation of return to the front line. It was found that repatriation led to symptoms becoming entrenched and also encouraged a hysterical contagion to others.
Increasing public concern in the UK led to the Royal Society of Medicine Symposium on Shellshock in Jan 1916, where a consensus was sought. Some measure of the size of the problem can be gauged by the figures for the 12 month period up to April 30th 1916, when 1300 Officers and 10,000 other ranks were repatriated because of shell-shock.
By July 1916, shellshock was widely accepted as a legitimate label for disturbed behaviour not caused by any physical injury, but the military authorities remained anxious to separate those suffering from this disorder from those with “insufficient stoutness of heart”, a euphemism for cowardice.
By WW2, both Commanders and their MOs had a much better understanding of shellshock. It was clearly understood that the syndrome involved a stress reaction which could occur either at the time of combat or some time afterwards, something we now know as Post Traumatic Stress Disorder (PTSD).
It was also known that the common initiating pathway was combat fatigue. Lack of sleep was an important factor. US studies during the Italian campaign found that one third of men in the frontline got less than four hours sleep per 24 hours. Only 13 per cent of troops got more than seven hours sleep.
Stress inoculation
Basic military skills training became extremely realistic and gave soldiers the confidence to be able to withstand combat stress. This process has been described as “stress inoculation”.
It was found empirically that soldiers operated at peak efficiency up to 90 days in the field and became burnt out after 200-240 days. During the Libyan campaign a “left out of battle scheme” meant that 20 per cent of front-line troops were regularly left in rear areas in order to recuperate from the stress of battle.
Total US neuropsychiatric casualties during WW2 numbered 400,000 of whom 25 per cent were repatriated.
The pattern of stress symptoms became changed and motor hysteria was replaced by cardiac and gastrointestinal symptoms. Advances in neurology meant that limb paralysis had become too easily diagnosed as hysterical.
The psychiatric casualty rate steadily diminished and was lowest after the Vietnam War. The major problem after this conflict was the late emergence of PTSD.
Individual susceptibility
Attention now became focused on the individual soldier and his or her susceptibility. For a period it was hoped that psychological screening on entry would detect those individuals most likely to become psychological casualties. This belief was tested during the Korean War and was found to be worthless. There was simply not enough time to screen candidates during enlistment. Despite this failure of prevention, the management of battle fatigue was considerably improved and only 6 per cent of psychiatric casualties had to be repatriated. This was due in part to a Command Policy that limited front-line service to a nine month rotation.
During the Vietnam War, it appeared that things were improving, with an all-time low casualty rate of 10-12 per thousand from war neurosis but it soon emerged that the major problem for veterans of this conflict was their integration back into civilian life. The Vietnam war was politically unpopular and it is hardly surprising that returned servicemen were met with hostility and rejection.
Fifteen percent of veterans (In NZ 20 per cent) claimed to be suffering from a disorder that became known as PTSD. This disorder entered the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980 after a prolonged campaign by well organised pressure groups and the label owes more to this process than any real scientific validity. Nevertheless, PTSD is defined as a constellation of symptoms and signs related to painful memories arising from experiences outside of normal human experience. The definition seems to have lost sight of the fact that shooting somebody or sticking a bayonet in them is generally outside of normal human experience. PTSD is believed to be caused by psychological arousal that produces chronic symptoms of anxiety and emotional withdrawal. In one major study that traced over three million Vietnam vets, 25 per cent were suffering some degree of PTSD.
Falklands War
The situation was even worse following the Falklands War. Fifty percent of veterans still serving had some of the symptoms of PTSD while 22 per cent had the complete PTSD syndrome as defined in DSM-III. Concerns at this high rate led one research project to look at the efficacy of psychological debriefing following experience of mental, physical or emotional trauma. It was hoped that an appropriate debrief would prevent the development of PTSD. Unfortunately the incidence of PTSD was exactly the same whether or not those exposed received immediate psychological debriefing.
In summary, up to the time of the Gulf War, there is a long recorded history of war-related psychological illness which start as battle fatigue and progress to either an acute neuropsychiatric syndrome or a much later expression as PTSD. The important question is whether GWS is a variation of PTSD or whether it is indeed some unique syndrome arising from some specific consequence of the Gulf War.
Chemical/biological threats
The Gulf War started with the Coalition forces ranged against the real threat of Iraqi troops hardened by years of war with Iran. The threat of chemical and biological weapons was also very real and the requirement to use respirators and restrictive protective clothing caused added stress in an already hostile environment. A US MO observed at the time that most acute medical problems had an emotional basis, frequently rooted in separation anxiety from family and friends. This is an exact modern description of Hofer’s nostalgia.
Soldiers were scared about chemical weapons, which is precisely the value of such agents. Panic, hyperventilation and inability to use respirators were reported in a number of subjects as was the inappropriate use of various remedies against chemical agents.
Since the Gulf War ended in 1991, large numbers of veterans have presented with a diversity of unexplained symptoms such as fatigue, headache, joint pains, skin rash, shortness of breath, sleep disturbances, difficulty concentrating and forgetfulness. It has been claimed by sufferers that GWS has somehow been transmitted to family members and even their medical attendants These symptoms have affected nearly 10 per cent of 697,000 US Veterans but only about one percent of 45,000 UK veterans. Some members of the Coalition forces have had no cases of GWS despite serving in exactly the same circumstances as those who claim to have the syndrome.
GWS has generated a vast number of studies and theories about causation. One such study costing $80 million and surveying 18,924 vets found “no single cause or mystery ailment to support suspicions about the existence of a GWS.” These findings have been confirmed by similar British and Canadian studies.
Random medical events
Despite these findings, researchers continue to promote ever more theories about the cause of GWS in which random medical events are now reported as proof of illness.
Over-investigation (the “million dollar work-up”) has produced unexpected laboratory results leading to further confusion and controversy about suspected aetiologies. Theories abound in direct proportion to the number of specialists involved and the mass media has become involved in popularising GWS with its disease of the month mentality. Veterans have developed a “fixed illness belief” characterised by paranoia and conspiracy theories. These are amply served by websites on the Internet and support groups. Veterans react angrily to any suggestion that GWS has a psychological basis such as a form of PTSD.
Throughout all of this, the US Government has been cautious and sympathetic and Vets with GWS are entitled to disability payments.
I believe that GWS is a functional disorder arising from psychological arousal. In other words, a somatoform disorder. The rates of symptoms reported are the same as in the civilian community and this explains the resemblance to Chronic Fatigue syndrome (CFS) which has an identical causation. GWS should be labeled with the more generic description of post-war syndrome.
Failure to recognise this has led to an entrenched illness perception with associated paranoia and conspiracy delusions. Continued over-investigation and speculation has paralleled a similar process in CFS. This fundamental misunderstanding of the true nature of post-war syndromes has already led to a new variant – Balkans Syndrome alleged to be due to exposure to depleted uranium.
A combination of factors
My own theory as to the actual initiation of post-war syndromes is that they arise from a combination of factors such as Hofer’s nostalgia and a rejection of warfare as a means of solving disputes, with the major factor being psychological activation and the creation of perceived illness. This illness is real to the afflicted individuals and the real challenge is to work with them rather than deny their symptoms. No funding should be made available for conducting further investigations and tests as these are irrelevant to the causation of GWS.
Bibliography
Shell Shock, A History of the Changing Attitude to War Neurosis. Anthony Babington
Trauma and the Vietnam War Generation. Report of the Findings from the National Vietnam Veterans Readjustment Study 1990
Hystories, Hysterical Epidemics and Modern Media. Elaine Showalter
A History of Psychiatry. Edward Shorter
From Paralysis to Fatigue. A History of Psychosomatic Illness in the Modern Era. Edward Shorter.
Comprehensive Clinical Evaluation Program for Gulf War Veterans. Department of Defense 1995
Illness of Persian Gulf Veterans. Hearing Before Committess of Veteran’s Affairs Serial No. 102-51
She went to War. The Rhonda Cornum Story. Presidio Press 1992
GWS. Letter in BMJ 1995; 310:1073 (22 April)