The journey from moral inferiority to post-traumatic stress disorder

Alexander C McFarlane and David Forbes
Med J Aust 2015; 202 (7): 348-349. || doi: 10.5694/mja15.00201
Published online: 13 April 2015

What has been learned over the past century about the psychological injuries of war?

One of the striking differences between recent conflicts and the conflagrations of the past century is that the number of physical casualties has been drastically reduced, a change that has placed greater focus on the psychological costs of war. To place the enormity of earlier losses into context: around 14% of those who served in World War I died (over 60 000 Australians), and a further 40% (more than 156 000 men and women) were wounded, gassed or taken prisoner — at a time when the nation's population was only 4.9 million.1

Those who survived the Great War were regarded as fortunate, even if they returned home with crippling injuries. There was often little empathy for the psychological wounds of the veterans, construed by many as reflecting moral inferiority, compensation-seeking or “poor seed”. In particular, there was considerable debate within the medical profession as to whether the traumatic neurosis of war — shell shock — was organic or psychogenic in origin.2

Recognition of post-traumatic stress disorder

Veterans of the Vietnam War confronted the medical establishment in the United States and Australia about the lack of understanding for their mental suffering shown by veterans' affairs officials. They demanded that quality scientific research be undertaken to better characterise the nature and cause of their psychological injuries, as well as to facilitate the development of effective treatments. Independent research, including the seminal US National Vietnam Veterans' Readjustment Study (NVVRS), showed that post-traumatic stress disorder (PTSD) was not explained by a desire for compensation, but was caused by the cumulative burden of exposure to the horrors and privations of combat.3-5 The NVVRS found that the lifetime prevalence of PTSD in Vietnam War veterans was 18.7%.3

It is ironic that “traumatic neurosis” (an earlier name for PTSD) had been well characterised as early as 1890,6 but social and political factors had subsequently prevented its being systematically investigated. Over the past three decades, much has been learned by a generation of high-quality research that has used epidemiological tools to assess the aftermath of both combat and peacekeeping missions.5 The mental health sequelae of major deployments since 1990 have been systematically studied, and the mental health of the entire Australian Defence Force (ADF) was documented in 2010.7 The findings of these investigations highlight that exposure to human suffering, the risk of death and active involvement in combat are not only the major risk factors for PTSD, but also for major depressive disorder and other anxiety disorders.4,5,7 Furthermore, the similarities of traumatic exposures during modern peacekeeping operations are often greater than the differences experienced during deployment in a declared combat zone; the rates of psychiatric disorder in veterans following the two types of deployment are therefore quite similar.7

Suicidal ideation and suicide are of particular concern in veterans with PTSD, and the number of active duty suicides in the US armed forces over the past decade has caused increasing concern.8

While investigators routinely find substantial levels of psychiatric disorder in former members of the armed forces, the rates in currently serving personnel often do not differ substantially from those for the general community; nor are the rates of psychiatric disorder in deployed and non-deployed military personnel strikingly different, despite traumatic combat experiences. It should be remembered, however, that those who enlist in the defence forces are generally fitter than the population from which they are recruited, and this healthy worker effect is amplified by selecting the more resilient for deployment.7-9

Prevention and support

Selection processes — no matter how rigorous — cannot entirely avert the psychological injuries caused by repeated exposure to traumatic events. Lifetime exposure to traumatic stress (including pre-enlistment events) needs to be taken into account when calculating the risk of PTSD. Deployment rotation cycles that limit the periods of exposure are equally critical for managing risk.

A recent review by the US Institute of Medicine of military programs that aim to reduce the risk of PTSD highlighted the fact that there is little systematic evidence for the effectiveness of the most widely used approaches, such as psychoeducation, emotional decompression, psychological debriefing and resilience training, so that more research is needed.10 Postdeployment screening was the only approach endorsed by the review, and used by the ADF since 1998. Early recognition of PTSD not only enables rapid diagnosis and intervention, but also assists when dealing with other barriers to effective care, such as stigmatisation of the patient.11 Adequate training of medical and mental health staff in understanding the various manifestations of traumatic reactions (not just PTSD) is critical. Medical providers are often unaware of the military service of discharged veterans, so it is also essential that this information is routinely requested. High-risk groups, such as the physically ill and injured, require regular screening and follow-up, as delayed-onset PTSD is now recognised to be much more prevalent than was previously thought, particularly in veterans.11

More research into treatment is needed

The compelling need for better treatment outcomes has led to substantial investment in research programs by departments of defence and veterans' affairs in the US, the Netherlands, the United Kingdom and Australia.12 Recent developments include the identification of epigenetic markers for PTSD, and recognition of the role of inflammation in its aetiology.13 Mild traumatic brain injury as a risk factor is also being extensively studied in military populations, highlighting the importance of the integrity of neural networks.14

Some effective treatments for PTSD have been comprehensively investigated, including cognitive behaviour therapy, eye movement desensitisation and reprocessing therapy, and antidepressant medication therapies, and it has been found that the effect size of these treatments is often smaller in veterans than in patients with PTSD following single-incident traumas.11 The prolonged hypervigilance and repeated exposure to traumatic experiences that characterise military deployments cause more significant neurobiological disturbances (eg, reduced anterior cingulate cortex volume), and conditioned traumatic triggers are less amenable to extinction.15 This profound neurobiological dysregulation needs to be targeted by treatment, with potential roles for both pharmacological and psychological interventions.15

The battle during World War I between organic and psychogenic models of post-traumatic stress was misguided. PTSD is a multifaceted disorder, in which biological, psychological and social components are entwined in its aetiology, and must therefore be considered in any recovery strategy. An effective way to honour the suffering of those who fought in World War I is to ensure that our care for the current generation of veterans is diligent and informed by independent and adequately funded high-quality science.

Provenance: Commissioned; externally peer reviewed.

  • Alexander C McFarlane1
  • David Forbes2

  • 1 University of Adelaide, Adelaide, SA.
  • 2 Australian Centre for Posttraumatic Mental Health, University of Melbourne, Melbourne, VIC.

Competing interests:

We receive funding from the Department of Veterans' Affairs and Department of Defence, and are advisors on mental health to these departments. Alexander McFarlane is a Group Captain in the Royal Australian Air Force Specialist Reserve.

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access_time 06:34, 25 April 2015
Ian Patrick (Paddy) Burges Watson

A systems approach to PTSD
To the Editor: McFarlane and Forbes are right about the need for better treatment outcomes for PTSD (1). The necessary enthusiasm for neurobiological research, however, is slowed by the labelling of PTSD as a psychological disorder. Psychology is of undoubted value in a wide range of physical disorders but cannot be of any further fundamental use in determining their nature - including PTSD (2).
The molecular response to threat and challenge is as old as life and its complexity at our end of the tree of life needs to be unravelled before we can hope to have a complete answer for its management. It is not just a brain disease but a systemic condition. The skin (3) and gut (4) and reproductive systems (5) invite particularly close attention but ultimately every part of the body is affected. It is only in the last few decades that we have known enough to be able to discover more!
In this, the centenary year of WWI, we do little honour to those who died or those who suffered the ‘mental’ scars of war by downgrading the condition to a sort of super distress state that right talking and right thinking will solve – much as both may help. During the next four years, while we go on commemorating the sacrifices made in WWI and subsequent wars, it would be good to see as much neurobiological research as schizophrenia regularly enjoys. We could then expect major advances in the treatment of PTSD and perhaps a better understanding of a range of ‘mental’ disorders.

(1) McFarlane AC, Forbes D. The journey from moral inferiority to post-traumatic stress disorder.
MJA 2015; 202 (7): 348-349.
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(3) Slominski A, Zbytek B, Nikolakis G et al. Steroidogenesis in the skin: implications for local immune functions.
J Steroid Biochem Mol Biol 2013; 137:107-23.
(4) Keightley PC, Koloski NA, Talley NJ. Pathways in gut-brain communication: Evidence for distinct gut-to-brain and brain-to-gut syndromes.
Aust N Z J Psychiatry 2015; 49(3):207-214.
(5) Kalantaridou SN, Zoumakis E, Makrigiannakis A et al.
Corticotropin-releasing hormone, stress and human reproduction: an update.
J Reprod Immunol 2010; 85(1):33-9.

Competing Interests: No relevant disclosures

Dr Ian Patrick (Paddy) Burges Watson
Hon Research Fellow, University of Tasmania

access_time 02:15, 1 May 2015
Alexander Cowell McFarlane

Burgess-Watson1 raises an interesting dilemma that is as old as Descarte’s deliberations about the nature of the mind2 and the origins of psychiatric illness. There is an increasing body of neurobiological research demonstrating the PTSD, as with many psychiatric disorders, has a general dysregulation of biological systems that are not confined to the central nervous system3.

The specificity of these changes, the question as to whether they are pre-existing, a consequence of stress exposure, changes indicative of the disorder or chronicity are important research questions in determining what drives the condition3. While Burgess-Watson argues for PTSD to be conceptualised as a system condition, even for PTSD to be accepted as a brain injury would be an important philosophical and legal step forward. The evidence for the enduring impact of stress exposure on health comes from prospective studies such as the Grant Study which found that combat exposure in a highly resilient group predicted premature mortality, supporting the argument that traumatic stress has systemic effects that are not confined to the brain4. Evidence about changes in systemic inflammation in PTSD support this hypothesis5.

While PTSD requires a biopsychosocial perspective to understand its manifestations, advances in understanding its biology, much of which is not likely to be confined to the brain will provide great advances in treatment.

AC McFarlane and D Forbes.

1. Burgess Watson - This volume
2. Broughton J, Mattern R. Reinterpreting Descartes on the Notion of the Union of Mind and Body, J Hist Philosophy 1978;16:23-32.
3. Pitman RK, Rasmusson AM, Koenen KC, et al. Biological studies of post-traumatic stress disorder.Nat Rev Neurosci 2012; 13:769-787.
4. Lee KA, Vailant GE, Torrey WC, et al. A 50 year prospective study of the psychological sequelae of World War II combat. Am J Psychiatry, 1995, 152;516-522.
5. Miller MW, Sadeh N. Traumatic stress, oxidative stress and post-traumatic stress disorder: neurodegeneration and the accelerated-aging hypothesis. Mol Psychiatry, 2014;19:1156-62

Competing Interests: The authors have funding from the Department of Veterans Affairs, the Department of Defence and the National Health and Medical Research Council

Prof Alexander Cowell McFarlane
Centre for Traumatic Stress Studies, The University of Adelaide

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