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What is combat stress?

By Dr Walter Busuttil, Consultant Psychiatrist and Director of Medical Services, Combat Stress.

War theatre mental breakdown or Combat Stress Reactions (CSRs) incorporate many features of Acute Stress Disorder (ASD). Initially prodromal high arousal, anxiety, and withdrawal followed by exposure to a severe psychologically traumatic event followed by gross psychiatric symptoms including cognitive impairment, dissociation, confusion and disorientation; with a final phase developing over several days or weeks comprising depression, guilt and shame; intrusive thoughts vivid images of traumatic event/s; sleep disturbance, fatigue and irritability.

CSR can spontaneously resolve, resolve following early intervention comprising rest and cognitive therapy based psychological interventions, or progress into long term psychiatric illness. These may include anxiety disorders, depression and alcohol misuse as well as Post Traumatic Stress Disorder (PTSD): characterised by re-experiencing symptoms including nightmares, flashbacks and intrusive memories; hyperarousal symptoms including hypervigilance, physical and psychological symptoms of anxiety including panic attacks and emotional numbing; and avoidance symptoms including social withdrawal. The main factor determining the development of CSR, ASD and PTSD is a dose response effect: the more severe and prolonged exposure to psychologically traumatic stressors is, the more likely it is that mental breakdown and illness will develop.

Recent studies demonstrate increased levels of PTSD of between 1 and 8% in British personnel deployed to Iraq or Afghanistan. These figures are low compared to US and Australian studies. The main reasons for are thought to be differences in the methodology of studies; as well as a lower dose response effect following the implementation of ‘harmony guidelines' that in comparison limit the duration and frequency of deployments for the British soldier. Psychiatric problems increase if these guidelines are breached, with particular difficulties in those whose tours are unexpectedly extended.

In-service psychiatric care is organised into multidisciplinary Departments of Community Health (DCMH) situated all over the UK and overseas. Access to high standard mental health care is rapid. Hospital services are contracted out to an NHS Consortium. In combat zones multidisciplinary Psychiatric Field Teams are deployed.

Clinical audits indicate that 5000 new referrals present per year and that common presentations include alcohol misuse, depression, anxiety and adjustment disorders with low rates of PTSD. Combat exposure is associated with higher levels of alcohol misuse especially in the younger servicemen. One recent study demonstrated that suicide rates for ex-serviceman under twenty-four years were two or three times higher than their civilian counterparts. Reasons for this unclear with causes suggested as including: pre-service vulnerability, trouble re-adjusting to civilian life and exposure to more adverse experiences.

Despite easily available mental health services many veterans report that they were unable to present for help with mental health problems during their military service. Reasons given include fears of losing their career, a macho image and stiff upper lip. Many report drinking alcohol to excess in order to cope with mental health symptoms. Delayed onset PTSD is common in British veterans and is more likely to develop during the first year post military discharge, suggesting that the loss of military support structures and adjustment to civilian life increase vulnerability.

In Britain a veteran is defined as someone who has served in the Armed forces for at least one day; there are 5.5 million veterans and 7.5 million family dependents. Since 1948 the NHS has been responsible in looking after the health of veterans. Until recently no specialist NHS services for veterans have existed. Within the last 18 months the MOD and NHS aided by the national charity for veteran's mental health Combat Stress set up six pilot sites across the country aimed at signposting veterans into mainstream mental health care. Other new NHS initiatives have included Improving Access into Psychological Therapies where it is hoped this will allow better access to psychotherapies. The MOD offers mental health assessment services to veterans at St Thomas' Hospital in London and for reservists at Chilwell in Nottingham.