Stress and Anxiety in New Missions in Caforio, G., A Handbuch of the Sociology of the Military, (Cham: Springer 2018) p 553-578

Abstract

Stress is a mental disorder, anxiety is a disease ignited by stress you cannot come to grips with. The two concepts are cause and effect. The most common and costly type of mental disorder is Post-Traumatic Stress Disorder, PTSD. Seven “Cs” describe here PTSD: Concept, Content, Chronology, Contributors, Consequences, Coping and Costs. 

Introduction

Two types of mental stress disorder for veterans exist related to the time for their occurrence: An acute Combat Stress Reaction, CSR, and a delayed reaction, Post-Traumatic Stress Disorder, PTSD. The PTSD concept is rather new, introduced in 1980. Two models show the rather different perceptions of how to define PTSD. One is a process model issued by the American Psychiatric Association, APA, including elements other than the “pure” diagnosis of PTSD. The other model suggested by National Institute of Mental Health, NIMH, deepens just the contents of PTSD itself by defining its biological, medical, chemical, social, functional, and psychological symptoms. Then, the content or specific symptoms of PTSD according to the APA model of 2013 is presented, problematized, and compared with the NIMH model. The chronology of PTSD-like symptoms in war history are old, however, with different names attached. PTSD has developed from ignorance for many centuries via recognition in the last half of the Nineteenth century of stress caused even for psychological reasons, then to be forgotten up to and after WWI, and since 1980 named, accepted, and attended. Four contributors or risk factors may create/increase PTSD, in particular. One civilian: Personal background and three military: Combat exposure, military organization and type of war waged. The new types of wars are identified, including missions led by the UN, NATO, the OSCE and others. They have not reduced the prevalence of PTSD. PTSD can lead to two types of consequence: Medical diseases and social disabilities, of which only the former is analysed. Its perspective has shifted from military effectiveness to society´s political, economic and ethical responsibility towards the veterans to minimize/cure medical illnesses and social inabilities caused by PTSD. Consequently, coping strategies have moved from zero, i.e. for the individual veteran self to handle to a massive effort for society to relieve PTSD sufferers, even if no single cure has yet proven to do so. Accordingly, costs for the caring of suffering veterans will increase for the simple reason that they first reach their peak decades after wars ended. Much research on PTSD are based on U.S. data; so, is this article. 

Concept

Stress, in general, is not “inevitably followed by symptoms or illness” (Clausen 1981: 393). It is like the “zero” in Mathematics. It has no value standing alone, but elements before and after define it. Stress, you can manage makes you stronger and more robust. Stress you cannot is characterised by a variety of symptoms that may develop illnesses and social inabilities. Stress “developing within one hour of exposure to the exceptional mental or physical disorder” (Weisaeth & Eitinger 1991:1) is “acute” stress, “delayed” stress begins six months after the trauma. Short-term stress may improve your concentration, for instance before a competition. Long-term stress weakens the resistance of your body. A “chronic” stress lasts for more than three months. Six cross-national PTSD studies give an impression the increased interest in PTSD veterans research over time: In 1991, Weisaeth & Eitinger only registered 50 articles on all PTSD suffers including concentration-camp inmates, children, Prisoner-of-War, veterans, etc. from 11 nations in Europe, the Middle East and Africa (Algeria). In 1994, Orr presented 10 articles and other 20 articles were annotated on PTSD veterans only from 11 countries). In 1999, Schnurr & Friedmann 1999 counted around 1.100 articles published from 1989 to 1999 by the National Center for PTSD in PTSD Research Quarterly and told that the number of connections/users to the Pilots Data Base has increased from 821 in 1992 to 2596 in 1999. In 2003, Taylor (2004:6) on a web search on “peacekeeping and stress” in four data bases, found 654 entries. In May 2015, 371.000 entries in Google were listed, while “stress and peacekeeping” gave 396.000 entries. In 2006, Peleg & Shalev could tell that studies of PTSD have increased from 159 in 1988 to 990 in 2004, and that the number of the costly, longitudinal PTSD studies went up from 2-9 studies in the period 1988-1997 to 31-33 studies in 2003-2004. In 2013, Norris & Slone informed on the worldwide research over the last ten years on PTSD in public and military populations. Finally, in 2014, Hunt et al. (2014) present the research efforts of 97 references of the last twelve years on the mental health of mostly just UK military personnel.

Psychologists and psychiatrists define the PTSD concept differently. In psychology, stress is defined as a special mental relationship between a person and his/hers environment, perceived as a strain threatening the well-being of that person. In psychiatry, stress is a mental as well as a physical disorder (due to an intracranial injury named Traumatic Brain Injury, TBI) having either a physiological or a psychiatric distorted impact on the body. Thus, the PTSD concept in psychiatry is broader with respect to both trauma, content, and cure than that of psychology. To both psychiatrists and psychologists PTSD is not an illness in itself, but a mental disorder defined less by its own symptoms than by its surrounding elements. It is less than 40 years ago, in 1980, that the APA for the first time described the PTSD disorder in its Diagnostic and Statistical Manual of Mental Disorder (DSM-III). It was a result of “…a political struggle waged by psychiatric workers and activists on behalf of the large number of Vietnam War Veterans who were then suffering the undiagnosed psychological effects of war-related trauma” (Young 1995:5). The present DSM-5 of 2013 model operates with four clusters and 20 symptoms distributed on eight criteria: A. Exposed to traumatic incident; B. Intrusion; C. Avoidance; D. Negative alterations in cognition and mood; E. Alterations in arousal and reactivity now including recklessness and self-destructive behaviour. On top of that, three parameters outside define PTSD: F. Duration; G. Social inability and H. Medical treatment is impossible. The DSM-5 definition with criterions “A-G” is shown in fig. 1 below together with its most recognized contributors or risk factors. 

Fig. 1 in here

Fig. 1. PTSD and its Elements According to APA version DSM-5                                              

Fig. 1 relates the four phenomenons of PTSD: An incident experienced during military deployment creates a trauma; a supressed or dissociated memory hereof and its incompatible self-perception may lead to one or more “stressor criterions A – G” or contents of PTSD. The single most important criterion is the “A” that specifies that a person has been exposed to a catastrophic incident involving actual or threatened death or injury. Criterions B-E is the veterans behavioral strategy towards PTSD, criterion F is the demand of duration of PTSD for at least one month, while G specifies the serious social consequences, and H lists that the symptoms are not due to medication; the vulnerable mental PTSD-position may further be strained by four contributors or risk factors. Two consequences may occur: Illnesses such as anxiety, fear, depression, and Inabilities such as unemployment, social isolation, divorce.  

“Trauma” in Greek means “wound.” A traumamatic event is conceptualized as a catastrophic stressor outside usual human experiences such as war, torture, rape, earthquakes, automobile crash, etc., while more normal life painful experiences such as serious illness, divorce, rejection, etc., are not. However, trauma, like pain, is not an external phenomenon that can be objectified. Any traumatic experience is filtered through cognitive and emotional processes before it becomes an extreme threat, in short a memory. 

Memory is a certain type of rememberence. It demands revival of the incident, an identification, and a creation of an identity. The search for meaning in the confrontation with a meaningless incident reinforces the veteran´s revival of the incident in an effort to better understand it even if the individual, at the same time, often tries to avoid thingking of it. “The disorder´s distinctive pathology is that it permits the past (memory) to relive in the present” (Young 1995:7). So, the core of the DSM-5 model is the struggle between the memory´s revival/avoidance, etc. of the extreme event and one´s self-identification, often further strained by the four contributors, cf. fig. 1. 

The DSM-5 PTSD diagnosis depends – as the earlier versions - not only on the patient´s symptoms but also on its consequences. From the vulnerable state of mind of PTSD, a number of illnesses may be ignited: Intense fear, nightmares, memory problems, reduced interest in significant activities, hypervigilance, concentration difficulties, anxiety, insomnia, depression, flash backs, etc. and social problems such as unemployment, divorce, loose of social contacts arise.

After the APA presentation of DSM-5 in spring 2013, the NIMH, officially abandoned it for its inability “to align with emerging findings from neuroscience and to capture the underlying mechanisms of dysfunction” (Karstoft 2014:153). Instead, NIMH suggested a new framework for PTSD classification, Research Domain Criteria, RDoC. It defines mental health by a matrix consisting on seven biomarkers and four behavioural elements. Each of the seven biomarkers: Molecules, cells, self-report, behaviour, psychology, neural circuits, and genes are placed on a dimensional scale ranging from normal to abnormal for each of the four behaviour elements: Function, motivation, cognition and social behaviour. Even if RDoC seems complicated with behavioural elements both among biomarkers and behaviours, more researchers use it to identify PTSD (Yehuda et al. 2014). An illustration of a biomarker diagnose diagram for two PTSD-veterans is shown in fig. 2 below.  

Fig 2. In here

Fig. 2. Two PTSD Veterans with Different Diagnosis Due to Their Biomarkers

Fig. 2 presents a perception of PTSD confined within its own symptoms. The centre “0” represents normality, 35 major abnormality; the seven biomarker radar-strings illustrate different degree of abnormality for each veteran. Veteran 1 has normal neural circuits, cf. the 0, but scores high on molecules, cells, and self-report. Veteran 2 has in particular psychological problems. 

Content

In 1952, APA published its first “Diagnostic and Statistical Manual of Mental Disorder, DSM-I” and in the DSM-III from 1980, it was accepted that soldiers may suffer from a disorder with a delayed onset, therefore named POST-traumatic Stress Disorder, PTSD. It saw the mental disorder as an individual delayed dysfunctional reaction on an experienced traumatic experience/incident that could hit all soldiers as an individual disease. In the DSM-IV version of 1994, APA introduced as the “most important change to PTSD…the “etiological agent,” i.e. the “stressor criterion”” (Young 1995:288; Friedman 2013:10). It is a death-involving event that the traumatized person has experienced or been confronted with to which he/she responds with intense fear, horror, and helplessness. The DSM-IV expanded the variety of experiences and memories to be used to diagnose PTSD (Young 1995:289) as even accounts of death and injury (in contrast to direct encounters) allows a PTSD diagnosis and excluded the demand of the DSM-III that the event had to be “outside the range of usual human experience” (killings, rapes, car crashes). The DSM-5 of 2013 with its four clusters and eight criteria of which “the “A” stressor criterion is maintained and the most decisive symptom of them all as it “made PTSD the only DSM mental disorder that required …an external environmental stressor as part of its diagnosis” (Barglow 2012). The DSM-5 revised its criteria A1 by eliminating “criteria A2 (the removal of the requirement that A1 events must produce fear, helplessness, or horror)” (Friedman et al. 2014:543). It introduced a new criteria D in order to encompass negative alterations in cognition and transform the former D to criteria E (Norris & Slone 2013:2). Thus, the “new criteria D and, in particular E (self-destructive behaviour) will enhance practitioners´ ability to capture the full array of symptoms among children that was not captured in the adult version of the current (DSM-IV) diagnosis” (Friedman et al. 2014:394). The DSM-5 version is further enlarged “to include anhedonic (lack of will to live)/dysphoric presentations” (Friedman 2013:11). Another change is that PTSD is no longer “considered an anxiety disorder, (but) …categorized as a trauma and a stress-related disorder” (Osei-Boamah et al 2013:3). It narrows PTSD as “any (PTSD) disorder has been preceded by exposure to trauma” (Friedman 2013:11). On the other hand, it expands the concept, as “stress” is a wider concept than “anxiety.” Finally, the PTSD content required additional social impairment, criterion F, to have lasted for at least one full month to fulfil the PTSD diagnosis. 

The DSM/5 PTSD concept is problematic for more reasons. Fig. 1 above may illustrate some of them: Some trauma victims do not report significant symptoms for a longer period of time and some of them do not report, at all (no box 3) (Gray et al. 2004:909). Some PTSD veterans lack trauma (no box 2), but still suffer the consequences (box 4) or the other way around: One third of the soldiers (36,8 %) showing the full PTSD symptom pattern on the SCID suffered no more than a slight impairment in their lives (Engelhard 2007:140-145). A study of PTSD among Vietnam veterans showed the same: Individuals - exposed to traumatic incidents with only minor PTSD symptoms and did qualify as having PTSD - lived well-adjusted, productive lives (Dohrenwend et al. 2006:979-982). Some PTSD veterans have not experienced a lethal incident (no box 1), but only heard/seen/red about them, cf. that DSM-5 accepts PTSD based on accounts. Some veterans do not meet any of the five criterions or symptoms (no box 3) but still suffer. For example, veterans suffering from the feeling of a constant “threat” may get ill and behave socially dysfunctional without meeting the required symptoms. The problems are thematically, as well: Medically, the diagnosis of PTSD in DSM-IV (and DSM-5) are “characterised by medically unexplained syndromes” (Jones & Wessely 2005:192). Psychologically, “the phenomenon of “delayed-onset” PTSD remains somewhat controversial.” (Richardson et al., 2010:11). Socially, “…different people react differently to extreme events and conceive differently what “a threat” is” (Young 1994:289). Scientifically, factors after PTSD defines its content. Functionally, the inclusion/exclusion of one or more of the five criterions decide if and what type of PTSD is at hand. By regulating the number and rates of PTSD veterans, the DSM-5 definition “fail to capture the heterogeneity of posttraumatic stress reactions (as it)…is too heterogeneous to be accurately predicted” (Galatzer-Levy & Bryant 2013). 

A major difference between the DSM-5 and the NIMH model is that the former includes a trauma, cf. post-TRAUMATIC stress, while the latter ignores elements before and after the PTSD symptoms. Another is the intensity of the NIMH model. It looks only at PTSD symptoms, but from many more angles than DSM-5. A third is that the existence of PTSD of the NIMH model rests on degrees of abnormality within one or more of the seven biomarkers by which a PTSD veteran is defined. In the DSM-5 model abnormality is both the five criterions A-D within the PTSD concept, and the trauma and the social consequences, criterion F, without it. In the NIHM model, all elements before and after the mental disorder are excluded. A fourth difference is the duration of PTSD for more than one month in the  DSM-5 model where no such demand exists in the NIMH model. A fifth difference is that the DSM model has, as described above, gradually expanded. A sixth difference is that DSM-IV (and DSM-5) “PTSD is a popular diagnosis because it has the virtue of clarity… (in contrast to) most psychiatric diagnoses (that) are descriptive, not aetiological…Saying that someone has depression is a statement about their symptoms…but not the cause. PTSD is the exception... it mentions the cause “trauma” (Jones & Wessely 2005:185). Seventh, the DSM/5 PTSD concept has expanded its purpose, as well. From a professional tool for psychiatrists and psychologists to wider understanding of a complex mental disorder to improve veterans´ access to benefits and compensations from society based on their PTSD diagnosis. 

The increased heterogeneous DSM/5 PTSD concept has not only met the above-mentioned scepticism but raised the more fundamental question:Who is actually sick? The PTSD-veteran or society? Some researchers see PTSD as an individual disorder among veterans leading to dysfunctional behaviour. Others see soldiers engaged in a war decided by society to which soldiers respond “normally” with distress on such an abnormal situation. This response is not a psychiatric one, but “normal (human) reactions to an abnormal situation,” (Jones & Wessely 2005:172).

Chronology

The perception over time of PTSD, its historical event, type of trauma, name, and symptoms is presented in table 1, below..  

Table 1 in here

Table 1. Trauma, PTSD Names, and Their Contents. 2800 B.C. - Today

Time & EventSource/AuthorTraumaPTSD nameContents or symptoms

2800-2600 BCEpic of Gilgamesh

Gerson et al (1992)Survived violent encounter-Inability to sleep

490 BC

Battle of Marathon

356-323 BC

Alexander the GreatCrocq+Crocq(2000)

Weisaeth (2014)

Involved years of bloody hand-to-hand combat-Change in personality

1648 

Westphalian Peace van Creveld (1991) “Military stress”

1500-1600

Colonial WarsRosen (1975)Spanish conscripts far from home“Nostalgia”

1795-1815 Napoleonic Wars soldiers suffered from PTSD like syndromes “Cerebral-spinal shock”tingling, twitching and even partial paralysis

1853-1856 

Crimean War “Palpitation”“Palpitation”

1861-1865

American Civil War and afterDa Costa (1871)

Erichsen

(1866/1882)distinct disorder identified

Chest pain, palpitations/

Erosion of ability to calculate & spell words“Da Costa syndrome”=

“Irritable heart”

“Railway spin”

Self-inflicted wounds, unexpected tremors, 

1890s The UK-“Melancholia”

1914-1918WW IThe sound from the large calibre artillery “Shell shock”Crying, confusion 

1920Sigmund Freud

(1920/1955)Psychological trauma produced…...“Neurosis” 

1939-1945“Combat fatigue”

“battle exhaustion”Of 800.000 combat soldier 37% had a psychiatric problem

1952 (DSM-I), APA “Gross stress reaction”

1950-1953Korean War“Operational fatigue”Of 200.000 US soldiers 25 % had eventually psychiatric problem 

1968DSM II

APA“Transient, situational  disturbance”

1980DSM III (1980) APAExtreme trauma eventPTSD

1994DSM-IV, APATraumaPTSDImpairment consequences

2013DSM-5

APATraumaPTSD, 8 criteria: 

F. For more than a month

H. Exclusion of medicationA. Exposure to extreme incident

B. Intrusion, C. Avoidance,        D. Negative cognition 

E. Alterations in arousal 

G. Severe functional impairment

2013Rod

NIMHNo trauma Dimensional abnormality with respect to……7 PTSD elements: Molecules, cells, self-report, behaviour, psychology, nerves, genes, 

Table 1 is based on the argument that PTSD is a “…relatively common human problem…known for many hundred years, although under different names” (Trimble 1985:5) and that “the disorder and its memories (goes) back to the dawn of recorded history…PTSD is a historical product…the reality of PTSD is confirmed empirically” (Jones 1995:3 + 5; Weisaeth 2001:38-59). King Gilgamesh who lived around 2800-2600 B.C. revealed PTSD symptoms according to The Epic of Gilgamesh (cf. Boehnlein & Kinzie 1992:598) who “after the loses of his friend Endiku…he races from place to place in panic, realizing that he too has to die” (Crocq & Crocq 2000:47). Crocq & Crocq moreover present PTSD among warriors from the battle of Marathon (Herodotus 440 BC), among Greek (Hippocrates 460?-377) and Roman soldiers suffering from frightening battle dreams (Lucretius´poem De Rerum Natura 50 BC), and among Vikings (Gisli Súrsson Saga) (2000:47-48). In the middle Ages, the distinction between soldiers and citizens based on experienced violence and followed by a trauma was blurred. With the Westphalian Peace Treaty of 1648, a specific “military stress” was identified in accordance with the Treaty´s distinction between state, society and military. Thus, the violence caused by states through their armed forces separated fear and anxiety among soldiers from that of the civil population (van Creveld 1991:40). In the sixteenth and seventeenth centuries, a new type of military stress named “nostalgia” is found in various Swiss and Spanish accounts on conscripts sent to foreign territories from where they had little prospect of returning home (Rosen 1975). In the Napoleonic Wars, 1795-1815, soldiers suffered from PTSD syndromes such as “cerebral-spinal shock,” evidenced by tingling, twitching and even partial paralysis by soldiers who had been close to projectiles, explosions but not injured physically. During the Crimean War, 1853-1856, “palpitation” was the name for the same disorder. PTSD-like veterans from the American Civil War 1860-1865 were diagnosed with an “irritable heart” (Da Costa 1871). Now, the hardships of campaigning and the acute stress of combat was accepted to cause an immediate mental effect on soldiers. Doctors in the British army in the nineteenth century preferred the diagnosis “melancholia” (Jones & Wessely 2005:3). At the end of the 1890s, a further step was that the recognition of a painful memory, even including previously forgotten incidences, could imply a psychological PTSD-like symptom called “repression” and “dissociation” (Young 1995:3f). The symptoms proved themselves in the individual reactions of the veteran (e.g. dysfunctional actions, inactivity, hysteria, bodily contractures, etc.). These new PTSD symptoms were almost identical with the one used during WW II, but were forgotten at the time of WWI. And even more so: WW I soldiers arguing that they suffered from military stress without having experienced physical incidents were seen as simulating their disease in order to get dismissed or transferred to less lethal quarters. In contrast, Sigmund Freud giving witness for “the Austrian Government Committee on War Negligence” wrote in 1920 a memorandum in which he described the PTSD-like diseases as “war neuroses” related to an unconscious interest of the soldier to withdraw from service, as it was dangerous (Freud 1955:206ff). From around WW II, Western societies have diagnosed many soldiers as suffering from a psychological disorder caused by psychological factors. Since 1980, PTSD has been the main concept to describe mental problems for veterans. Even if it is neither “the only injury nor occupational hazard facing service personnel …. (nor) the main issue… (as) depressive and alcohol disorders are more common” (Jones & Wessely 2005:184f). 

More patterns on the chronology of PTSD emerges. First, PTSD-like mental disorders are identified throughout in war history under no or different PTSD-names, but in most of the historical period, PTSD-like symptoms was not given any medical diagnosis. Second, a continuous and gradual understanding of PTSD does not exist. There is a lack of historical and theoretical continuity in the evolution of psychiatric knowledge of PTSD (Gerson et al. 1992:742; Jones 1995:5). Third, in the nineteenth century, war syndromes caused by physical incidents were accepted but forgotten up to, during and right after WW I. Fourth, acute Combat Stress Reaction, CSR, were recognized centuries before the delayed onset of PTSD was  introduced in 1980. Fifth, already before WW II and onwards, more nations accepted that their soldiers might suffer from PTSD for psychological reasons. Sixth, after WW II we talk more compassionate and forthcoming of these disorders than before. To conclude, “What changed was not the incidence of the disorder (PTSD) but the way it was classified and described. From being a heart disorder of mysterious organic cause to a functional disorder with psychological features” (Jones & Wessely 2005:196). 

“PTSD statistics are a moving target” (Veteran PTSD Statistics 2015:1). To compare the prevalence of PTSD by the numbers and rates for different nations and periods includes more reservations. First at the societal level, most PTSD studies exclude the influence of societal factors on PTSD such as “the gradual undermining of social stability and cohesion as well as the shift from collective to individual values, and the erosion of lack of trust in political and cultural institutions,” (Jones & Wessely 2005:173, originally Furedi 2003). 

A comparison of soldiers with PTSD over time within the same nation is problematic, as well. Changes in the welfare state and in the educational level is crucial. Recent veterans are more likely to have completed high school than were draftees during the Vietnam War. So is differences in military personnel and methodology. Even within the same decade and the same population of veterans from either Iraq or Afghanistan, differences in the rate of PTSD-prevalence for U.S. veterans are between 5 and 25 percent (Ramchand et al. 2007). Even more crucial seem nation to be. In a review of 39 PTSD studies from four wars, the Vietnam War (7), the Gulf War (16), and the Iraqi, and the Afghan war (16) covering soldiers from the US, the UK, Australia, Canada, Kuwait, etc. PTSD affected 14-16 % for deployed US military personnel but only 7-8 % of the general population. In contrast, the PTSD rate for UK veterans from the Iraqi and the Afghan war was only between 3-6% (Gates et al. 2012:361-382). Another article comparing 17 PTSD studies from the US, 7 from the UK, 3 from Canada and 2 from Australia with respect to lifetime and current PTSD prevalence. The study found a current PTSD rate between 2–17 % for the US Vietnam War veterans, 4-17 % for US Iraqi war veterans but only between 3 - 6 % for UK Iraqi War veterans while lifetime PTSD for Australian veterans was 21 % and 12 % for current PTSD, and for Canadian soldiers respectively 7 % and 3 % 

(Richardson et al. 2010: table 1, p 20 - 22). Therefore, the review concludes: “Lower ceiling and more narrow range among other Western veterans” than that of U.S. military veterans (Richardson et al. 2010:12). 

The PTSD rate is influenced by the presence or absence of compensations, as well. If society offers no compensation to soldiers with PTSD, the veterans of this country do not bother to register as victims of PTSD. The health beliefs of the civil society influence the number of veterans with military stress, too: “In particular, ideas about acceptable levels of casualties and the general level of psychological understanding are pertinent. In the decade before the Boer War, when life expectancy for UK males was only 44 years and knowledge about syndromes was embryonic observed psychiatric casualty rates were so low as to be almost non-existent. (…) Expectations of survival and quality of life were far lower in 1918 than in, say 1968 and the contrast between civilian and military life less dramatic” (Jones & Wessely 2005:119). Finally, the stability of the nation is important. A survey of De Jong et al. (2001:555-562) found much higher PTSD rates in conflict areas such as Algeria (37%), Cambodia (28 %), Ethiopia (16 %), and Gaza (18 %) than in less volatile Western nations). Still, the U.S. stand out. Kessler & Üstün (2008), after collecting data from nearly 200.000 respondents in 27 different countries on four continents found a lower life time prevalence of PTSD in most of the surveyed countries (below 5 % in Ukraine to only 2 % or less in Israel, Spain, China, and Italy) than in the U.S.   

Therefore, any PTSD level for veterans shall be related to that of each nation, in general. If, “at any given time, perhaps 15 % of the US population is in need of mental health service” (Olsen & Micklin 1981:390), one should not wonder if there is a PTSD rate for veterans between 5 - 10 %. On the contrary. The PTSD level for veterans should expectedly be lower than the one for the entire population, as soldiers in most countries are screened before recruitment and deployment. However, that is not the case. “It is estimated that 7 % to 8 % of the US population will have PTSD at some point during their lives (while) more recent data estimate that PTSD affects 11 % of veterans returning from Afghanistan and 20 % of veterans returning from Iraq” (Osei-Boamah et al 2013:1f; NIH Medicine Plus 2009:10-14). 

Second, at the scientific level “most literature on delayed (onset PTSD)… (is based on) small case studies and anecdotes, that only limiting conclusions can be drawn” (Jones & Wessely 2005:183). Besides, variables as number of deployments, duration of service, force type, and rank are most seldom identical. Third, at the methodological level PTSD data can be collected either by “following soldiers on the battlefield…or (by) identifying soldiers with PTSD and go back in history” (Jones & Wessely 2005:176). The former measures PTSD accurately, but is very difficult to undertake and very seldom used. The latter is easier to do, but less precise. For the simple reason that “researches may lose track of military personnel once they retire… (as)… there are over 2.3 million American veterans of the Iraq and Afghanistan wars (compared to the 2.6 million Vietnam veterans who fought in Vietnam and the 8.2 million “Vietnam Era Veterans” (personnel who served anywhere during any time of the Vietnam War)” (Veterans PTSD Statics 2013:1). Fourth, at the medical level, “many observational studies are unable to distinguish between delayed presentation (they were there from the beginning) and delayed onset…it is not satisfactory for showing delayed onset by looking at clinical records…most PTSD studies are retrospective… based on self-report that are seriously flawed…many confuse cause and effect” (Jones & Wessely 2005:179-184). Fifth, at the quantitative level, more veterans claim VA care. Even if the total U.S. veteran population has decreased by 17 percent from 26,1 million in FY 2001 to 21,6 million in FY 2014, the VA enrolled veteran population has increased by 78 percent in the same period from 5,12 million to 9,11 million (Bagalman 2014::4, table 1). Sixth, at the qualitative level it is difficult to measure the effect of differences in compared studies. What is, for instance, the statistical significance for the rate of PTSD veterans diagnosed either

- for all types of military personnel or only combat soldiers, 

- having served at home or in a target country abroad  

- within a six months period of return from battle or over a whole life span,

- by self-reports or clinical studies

- by a psychiatrist, a psychologist or a lay observer/interviewer, etc.?

- by more or just a few criteria 

- anonymously or openly.

However, even if comparison of studies over time, borders, and background  is problematic, some over-all impression of the prevalence and rate of PTSD for veterans are possible. First, different wars have different PTSD rates for veterans. The PTSD rates for the Iraqi War are higher than for the Afghan War for US PTSD veterans (2010:10). Another is that “…the prevalence range (of PTSD) is narrower and tends to have a lower ceiling among veterans of non-US Western nations” (Richardson et al. 2010:12). A third is that fewer civilians than veterans (in the U.S.) suffer from PTSD. A fourth is that any PTSD rate depends on a specific definition of PTSD. If changed, the number and rate of PTSD will do so. “Studies… typically find that roughly half of the (US) veterans who had PTSD at some point in the past do not meet diagnostic criteria for current PTSD” (Richardson et al., 2010:11; Barglow 2012). Others have identified the same drop in PTSD rates (Dohrendwend, et.al. 2006; McNally 2007a & 2007b; Hoge, et. al. 2004). The introduction of the DSM-IV “has ultimately decreased the prevalence rate of PTSD” (Richardson et al. 2010:8), cf. that the annual PTSD “cases of not previously deployed US Service personnel” went up from 1611 in 2000, 2287 in 2005, 2969 in 2010 and then dropped to 1942 by October 2014 (Congressional Research Service 2014:2, table 2). However, the latest change in definition of PTSD has had only a minor effect: “Most patients (97.5 %) (of a sample of almost 3.000 patients) who met DSM-IV criteria also met DSM-5” (Norris & Slone 2013:2). A fifth trend is that over time the PTSD rates increase. A re-analysis of Vietnam veterans found “that contrary to the initial analysis of the NVVRS data, a large majority of Vietnam Veterans struggled with chronic PTSD symptoms, with four out of five reporting recent symptoms when interviewed 20-25 years after Vietnam,” (Price 2014). A sixth trend is that “retrospective studies of….Korean War veterans, Lebanon War veterans, and World War II veterans indicate that the duration of “chronic PTSD” can span an entire adult lifetime” (Richardson et al. 2010:11). In short, “PTSD is an occupational hazard of military life” (Jones & Wessely 2005:175).    

Contributors

Four risk factors may worsen PTSD, in particular. One civilian, the soldier´s personal background and situation and three military factors, combat exposures military organizational elements and finally the specific type of war.     

A personal background has many aspects: Psychological, personal, social, matrimonial, educational, and economical. Veterans with previously diagnosed psychiatric disorder and genetic inherited mental problems run, in particular, the risk of getting PTSD (Jones & Wessely 2005:175; Rona et al., 2009; Brewin et al. 2000). Personal factors such as ethnicity, lower intelligence, and lower age are other PTSD contributors (Jones & Wessely 2005:175) as well as being “enlisted and current smokers and problem drinkers” (Richardson et al. 2010:4). Lack of relation to loved ones and family is another aspect that correlates with PTSD (Mouthaan et al. 2005:101-114; Jones & Wessely 2005:175). Single or divorced officers and soldiers are more likely to get PTSD than married military personnel (Greenberg et al. 2008:78ff; Richardson et al. 2007:8) and so is those with “lower education and lack of educational achievement” (Jones & Wessely 2005:175; Richardson et al. 2010:4). Actually, for many PTSD veterans home is where stressors always are, both before, during and after deployment (Kold & Soerensen 2013:233-254).

Aspects of combat exposure as a military contributor to cause PTSD involve its intensity, number of deployments, their duration, time between deployments, and types of operation. In general, soldiers exposed to combat exposure are more at risk of getting PTSD than other military personnel (Richardson et al. 2010:12; Tanielian & Jaycox 2008; Institute of Medicine 2008; and Rona et al 2007 for UK armed forces). A significant association was, moreover, found between the duration of deployment and the likeliness to develop PTSD, while the number of deployments and PTSD was not identified (Rona et al 207: 506-511). A review study of Canadian soldiers realized an over-all relation between combat exposure and PTSD, as well, but no relation between combat and an increased risk of suicide (Sareen et al. 2010:464). Another analysis comparing 91 WW II veterans in 1946 and in 1988, predicted a relation between combat exposures and symptoms of PTSD together with early attrition and death (Lee et al., 1995:516). In the Soldier/Marine Well-Being Survey of the US Army’s Mental Health Team Advisory surveying 1.320 soldiers in 2006, the number of combat exposures correlates with PTSD, as well. Besides, the study found that duration of operation, deployment frequency, and time between deployments played a role for creating PTSD, as well (Castro & McGurk 2007). With respect to combat intensity “...it was established (during WW II) that the higher the killed and wounded rate, the greater risk of psychological break down” (Jones & Wessely 2001a). A study of Vietnam veterans showed that even if 93 % of the Vietnam veterans had served in Vietnam war-zones, only 41 % of the total sample had objective evidence of combat exposure documented in their military record (Frueh 2005:467). It may question the just mentioned results of a clear relation between combat exposure and war syndromes as Vietnam “combat” and “non-combat” groups do not differ on relevant clinical variables. With respect to the number of deployments in combat operations and increased possibility of PTSD one study found that duration of operation, deployment frequency, and time between deployments did play a role for creating PTSD (Castro & McGurk 2007). It corresponds with a study for around 1.300 Canadian peacekeeping soldiers deployed to the former Yugoslavia. It found a PTSD rate of “only” 10.92 % for veterans deployed once and a 14.84 % rate for veterans deployed more times (Richardson et al. 2007). With respect to the duration of the deployment period and risk of PTSD one study showed that longer deployments and first time deployments are associated with an increase in distress score (Castro & McGurk 2007). An analysis indicated that 4 months deployment period were less distressing than a 6 months period, suggesting that deployment length is a predictor of psychological health (Adler et al.  2005:122). At the same time, this study found that deployment length predicts soldiers´ adjustment. They mentally adapt to the deployment period: “These studies on soldiers in peacekeeping mission is based on a constabulary model, and thus it differs from combat operations in its fundamental approach and expectations” (Adler et al. 2005:121).   

Aspects of the military organization as a contributor to PTSD are lack of cohesion, rank, and type of branch. It is a basic finding in military sociology that cohesion improve soldiers’ endurance and robustness (Shils & Janowitz 1948). Even so and the fact that “1 million peacekeepers worldwide have served abroad, little is known about this phenomenon in peacekeeping” (Mouthaan et al. 2005:103). Both views have been questioned:”…a large body of empirical research on military and non-military groups showing that social cohesion has no independent impact on performance” (MacCoun et al.:2006:646). Low rank is important for a higher PTSD rate, as officers are less likely to get PTSD than NCOs and regulars (Greenberg et al. 2008:78; Richardson et al. 2007:8). Besides unit cohesion and rank, type of force and service is related to PTSD. Higher risks of PTSD were found for U.S. Army soldiers, U. S. National Guard, and U.S. reservists than for other groups of military service members of the U.S. (Tanielian & Jaycox 2008). In a study of soldiers returning from the Iraq war it was shown that type of force had an impact on various aspects of mental health service use (Fikretoglu et al. 2009:358-366). 

Aspects of the types of war waged as contributor to PTSD are their purpose, the present war ethics and laws, military technology, war performance in terms of speed and range, etc. (Wright, 1942: 88). In a world perspective, four distinctive types of war can be identified after 1945: Liberation wars (1945-1980), Cold War (1945-1990), civil wars in the former colonies during the same period (van Creveld, 1991:192ff; Hirst, 2001:94; Ramsbotham, 2005:81), and peace operations (1948- and onwards) based on the UN charter, chapter VI (peace-keeping) and VII (peace-enforcement). In each and every war, soldiers may suffer from war syndromes. But it is interesting that (UN-) peace operations may cause PTSD, as well. The first generation UN peace operations (1945–1989) were symmetric non-coercive state-state operations with the objective to keep the agreed truce after a period of war (Moskos 1976; Tardy, 2004; Ramsbotham, 2005). Here soldiers just made “a blue thin line” between the two belligerent actors causing little war syndromes except boredom. The second generation (1989-1999) - after the Cold War – changed wars from symmetric to asymmetric conflicts where nations intervened in civil wars (Boulden, 2001: 83; Duffield 2001; Tardy 2004) and made the new peace operations increasingly more complex than the former maintaining of a ceasefire (Dobbie 1994; Ramsbotham, 2005; Tardy, 2004). The third generation (1999 onwards) have changed peace operations into asymmetric interventions, as well, and the root of these conflicts cause large state conflicts and terror, named “new wars” (Kaldor, 1998; Münkler, 2005) or “hybrid wars” (Fleming, 2011; Tardy, 2004). 

The are more reasons for increased risk of PTSD among soldiers in these new missions. First, the conflict scenario has now changed into a state–culture scenario (Kaldor, 1998; Duffield, 2001; Ramsbotham, 2005; Pretorius, 2008: 100; Maguen, 2006), whereby deep cultural and religious identity processes become part of the asymmetric conflict. Instead of symmetrical visible military capacities soldiers are confronted by cultural symbols, behavior and languages they don’t understand, and they themselves perform cultural practices, which the local populations, in turn, don’t understand (Duffey, 2000; Rubinstein, 2008; Rosén, 2009, Kold 2013). Another contributor is that third generation of peace operations stresses soldiers more than before as they combine potentially lethal situations with the task of an individual self-control, cf. the UN soldier stress syndrome, (Wiesaeth 1990) where soldiers feel a strain between their aggressive or retaliatory impulses and forced non-reaction (Adler et al. 2005:121). In the same way, peacekeeping may be difficult to reconcile for some combat-trained soldiers and create a risk for PTSD, the professional soldier stress syndrome (Litz et al. 1997:178-184). Third, a specific external control is imposed on UN- and other peace soldiers by the laws of war and the Rules of Engagement (ROE) in the midst of battle. In particular, “ambiguities in how to interpret the ROE were commonplace, leading not only to confusion and frustration but also to feelings of moral ambivalence” (Franke 1999:126), see also Litz et al. 1997; and Adler et al. 2005:121). The problems with ROE is supported in an international study of nine-nations´ involvement in international military operations abroad. “Only 28,6 % (of the interviewed 542 soldiers) consider them (ROE) adequate and a fifth of the interviewees did not answer” (Martinez 2013:87). A fourth stress factor is the fact that UN soldiers previously did not expect and were not emotionally prepared to fight asymmetrically and kill children, women and enemies in civilian clothes as they now have to do. In contrast, a perceived meaningfulness of the mission, post-deployment social supports, and positive perception of homecoming were associated with lower likelihood of distress (Sareen et al. 2010:464-472, Franke 1999). Fifth, the frequency and the intensity of wars, as well as the number of deaths, has declined sharply over the last half century (Pinker 2011). It stands in contrast to the increased rate of veterans with a PTSD diagnosis and may be a result of a public, more than a political, “war fatique.” Sixth, even if the nature of conflict most certainly will continue to change towards increasingly use of unmanned systems, for instance when remotely piloted aircraft attacks an unmanned oil installation, the military personnel serving such weapons may still suffer mentally when they later on realize the violence they have inflicted on others. The conclusion is that the new types of wars and the new missions by the UN, NATO, OSCE, “Coalitions of the willing” and others have not reduced the prevalence of PTSD among veterans. 

The four main contributors for PTSD may be mutual related so that a soldier who is single, lacks social support, and have low education is almost by definition no officer and cannot improve social cohesion. The combined effect of these contributors will more probably expose such a soldier to PTSD than the average soldier. On the other hand, each contributor is no clear-cut  cause of PTSD. They are probabilities and tendencies, no one-to-one relation. 

Consequences

Two types of consequences may occur due to PTSD: Illnesses and social inabilities. Thematically, five types of diseases caused by PTSD symptoms can be listed: Biological “pressures on the arteries of the chest” (Jones & Wessely 2005:191), psychological, “constitutional inferiority…reduced memory” (Jones & Wessely, 2005:191), medical “toxic exposure…bacterial infection”, psychiatric, “schizophrenia,” and social “lack of adaption, social incompetence”. Two types of social relation inabilities that can be identified: Material or income related inabilities such as loses of jobs, higher unemployment and divorce rates (Angrist 1990). They can be estimated economically in contrast to immaterial related loses - often related to family - such as lost contacts to family, children, friends, and to one self, i.e. lost self-confidence, quality of life, etc. (Wool 2013). 

Thus, four consequences stems from any war: Its military expenses, direct costs of care to ill veterans (from the loss of lives and limbs via disability payments and medical care expenditures), indirect or individual costs such as loses of material related inabilities, and finally immaterial loses. Compared to the military expenses for the U.S. of waging war it seems reasonable to involve not only the direct and direct costs, but also try to price tag immaterial costs, as well. So, the next time a nation consider joining a multilateral military mission abroad, it should multiply its immediate military costs by a factor of two or more to get a more realistic amount of the total costs of waging wars.   

Coping

Three aspects of coping is touched upon here. Its historical development, the types of treatments, and views on their success. The history of treating war syndrome veterans starts with aid of fellow soldiers and the military system. In 1678, Johannes Hofer believed that war syndromes was due to pathological processes in those parts of the mind where images of desired persons and places were stored. Treatment, in the form of purges, was specific diets and digestion thereby freeing up vital spirits. After the American Civil War, one of the first psychiatric hospitals for veterans with war syndromes was established. Here, physicians tried to explain and treat soldiers suffering from different unexplainable somatic disorders, such as “Disordered Action of the Heart”, DAH, and psychogenic rheumatism. For the British war veterans with PTSD, the British War Office Committee´s coping strategy was: “Good results will in a majority of incidence be achieved with the most simple forms for psycho-therapy.” (1923:150). It is fair to say that treatment of PTSD first begun after WWII based on the idea that extreme experiences produce memories, normally concealed for the affected person, but with the intervention of a civilian expert the sufferer might be helped. The “significant change… in the PTSD (was) the stipulation that the etiological agent was outside the individual (…the trauma) rather than an inherent individual weakness” (Friedman 2013:10; see also Institute of Medicine 2014: Treatment). 

The five coping tools used to treat PTSD veterans are individual or group psychotherapy, cognitive behavioural therapies (both conversations), medication (pharmacology), psychosocial and integrated interventionism (by force). The first tool “psychotherapy…falls into three broad categories: Behavioural therapy, Cognitive therapy, and psychodynamic therapy (including hypnotherapy)” (Young 1995:176). The most successful interventions are cognitive-behavioural therapy, CBT, (Schnurr 2008:2), compared to medication: “It is clear that CBT has consistently proven more effective than pharmacotherapy” (Friedman 2008:6). Promising results are moreover obtained with specific CBT approaches such as Prolonged Exposure therapy, PE. Actually, Institute of Medicine have concluded that “…therapies that include exposure as part of the treatment such as CPT are the only types of psychotherapies that have been found effective for PTSD” (2008; see also Foa et al. 2009; and Friedman 2013:14f). Jones & Wessely agree: “cognitive behavioural therapies has provided the best evidence of efficiency,” (2005:187), but also, “interventions might prove promising” (Foa & Rothbaum 1989). In contrast, the debriefing system (the individual veteran´s conversation with a psychologist) used by many military organizations seems less effective. 

Three shifts in the coping treatment over the last half century can be observed: From military coping actors to civilian professionals. In pace with the research of contributors of war syndromes the emergence of a new class of authorities, medical and mental experts have claimed access to memory contents that owners (veterans) were hiding from themselves (Young 1995: 4) and thereby excluding the military experts from handling war syndromes. One reason for civil professions to help veterans with war syndromes is the fact that most veterans are no longer serving in the military but living and working in the community as civilians. Another is that military treatments were extreme such as court-martials, executions or electroshock (Freud 1955:212F). From fewer to more coping tool. Today, a wide range of war syndrome treatment tools compete and neither has won the battle. Rather, they often cooperate. At the same time, these civilian physicians and psychiatrists increase their knowledge about the emotional impact of peacekeeping and try to cope by relating the PTSD to the stress igniting extreme incident, its trauma, and contributors. From military arguments for coping with PTSD to individual considerations. Previously, any screening of recruits served the purpose of military organizational efficiency on the battlefield. Now, it also serves the obligation of any nation participating in international military peace operations to take care of its veterans. 

No matter these shifts, both psychiatric and psychological experts see PTSD differently. Most of them define PTSD as an individual syndrome; others see it as a societal phenomenon: “Treatment of the individual is not required because the trauma affects the whole society” (Jones & Wessely 2005:172). They argue that war syndromes are a functional response to a dysfunctional societal incident (Summerfield 1999; Bracken 2001). “Sufferings cannot be reduced to a diagnosis,” (Jones and Wessely 2005:172). The disagreement rests on a criticism of the criterion A of PTSD. It has ”…made PTSD the only DSM mental disorder that required...an external environmental stressor as part of its diagnosis… (Thus,) the use of the PTSD diagnosis may contribute to treatment failures because it fabricates a spurious invalid category of illness, rather than seeing a unique sufferer (which) a strict application of Criterion A of the PTSD diagnosis does not accomplish” (Barglow 2012:6).

Cost

Decisions on public benefits to veterans starts by how to define them. Either as anyone who have served in the armed forces (The U.S., Canada, UK), all former armed forces personnel having served in war or warlike circumstances (the Netherlands, Belgium, Indonesia, Russia), military personnel having served in specific wars (Albania, Bulgaria), or veterans do not formally exists (Germany, before 2013:Denmark) (Leigh & Born 2008: 300 – 304, box 18.1). Then, the criteria for receiving benefits as a veteran has to be defined. Either according to the veteran´s type of service (combat/non-combat, deployed/at home (the U.S.), injuries (most Western countries), needs of the veteran (Canada), or the type of war in which the veteran was enrolled (Russia and Romania distinguish between World War II veterans and other war veterans). Next, the three main types of benefits offered veterans must be decided. Either material/financial benefits, (compensation for loss of lives, limbs, income, health, working ability, health care), non-material benefits (psychiatric/psychological help, social work and relations), or commemorations (cemeteries, celebrating national veteran´s day). Finally, the providers of care has to be identified. Either a special ministry (Department of Veteran Affairs in the U.S., Department of Veterans´ Affairs in Australia, or Veterans Affairs Canada in Canada), a shared responsibility between the department of defence and civil ministries (the UK, France, the Netherlands), a civil ministry alone (Norway, Spain), or a partner model of governments, more ministries, military, civil organization, private associations (Denmark) (Leigh & Born 2008:197-199).

Thus, the cost of PTSD for any nation depends on its definition of veterans, their benefits, and providers. The care system in the U.S. is the Department of Veteran Affairs, VA, that helps the veterans while the Department of Defence, DoD, pays for the cost for the health of its active personnel. Even if the concept of PTSD is rather new, The U.S. veteran care system has a nearly 400-year history based on principles of social justice, where a society provides fair treatment to its citizens (Committee 2007: 47 + 51). Three issues will be addressed to get an impression of the costs of PTSD: 

- the number of veterans helped by VA, including the number of PTSD veterans

- the total costs of wars, both direct military spending and costs to disabled veterans

- the proportion of PTSD veteran care users and their share of the care system compared to other veteran beneficiaries. 

The first issue, the number of veterans, of veteran care users and of PTSD veterans for the three major wars waged by the U.S. in Vietnam, Iraq, and Afghanistan is shown in the first four columns in table 2. The last column includes all deployed soldiers and veterans in the U.S. by 2013, no matter the type of war in which he/she participated.

Table 2 in here

Table 2. U.S. Veterans, Veteran Care Users and PTSD-Veterans 1988–2013.

        Vietnam War  

1988               2014   Iraq + Afghanistan wars       

   2004               Oct. 2007         All wars by  

       2013

Veterans or deployed U.S soldiers3,100.000       2,500.000   1,140.0001,640.000                21,882.000

All enrolled

in VA care                     (1,200.000)

     -   -                   9,300.000

PTSD veterans479.000       700.000     215.900300.500          o.  500.000

PTSD veterans/

all soldiers  15 %                 28 %        21 %   18 %                           2 %

PTSD/All Beneficiaries                         (58 %)     -  -                           6 %

Table 2 shows the drop in the number of Vienam War veterans from 3,1 million in 1988 to 2,5 million in 2014 while the number of Vietnam War veterans enrolled in VA care grew from 479.000 to 700.000. The decrease of Vietnam War veterans by 600.000 is associated with deaths and suicides. More than 100.000 of the Vietnam War veterans have committed suicide since 1972, twice the number of killed U.S. soldiers in the Vietnam War. While the number of all veterans dropped, the proportion of PTSD veterans grew from 15 to 28 percent (Kulka et al. 1988, vol 1: 2; Vietnam War Veterans 2014:1-2). Before the wars in Afghanistan and Iraq in 1999, the number of PTSD veterans was 120.200. In 2004, it grew to 215.900. Thus, 21 % or one out of five deployed veterans suffered from PTSD (Committee et al 2007: VIII table 1). In 2007, this relation dropped to 18 %. In 2013, 9,300.000 veterans got VA care out of the actual number of U.S. veterans of 22,000.000 or 42 % (Department of Veteran Affairs 2014:”Expenditures”) and “more than half a million veterans (of the 9,3 million)…have sought care for PTSD through VA Health care services – making up 9,2 percent of all VA users” (Institute of Medicine 2014:2). Thus in the beginning, the relative number of PTSD veterans to all VA beneficiaries is rather low, but it will increase over time, cf. the development of PTSD veterans from the Vietnam War to all enrolled VA veterans.

The next issue to be pursued is the total costs of war, including not only direct military spending and historical and projected veteran benefits, but also the economic loss due to killed and wounded soldiers even if such figures are financially debatable, cf. table 3.    

Table 3 in here

Table 3. Total Costs for the U.S. of Three Wars, Including Cost of Killed and 

             Wounded Veterans. 1964 -2014  

Vietnam War 

(1964 – 1972)First Gulf War 

(1990 – 1991)Iraq and Afghanistan (OEF/OIF)    (2001 -> )   

 Edwards (2012)      Cost of War (2015) 

                              2001-2014      2014 ->

Direct military cost, 

 BN of 2008 $          899           96      1.559 1.543            79 =  1.622

Historical and projected Veterans’ benefits BN 2008 $         555          372         673    160        1.000 = 1.160 

Other costs (DoD, Homeland Security, Interests, Pakistan, etc.)            -(1.672)                   -

Total costs in BN 2008 $

       1,424 

        468      

      2,232(3.375)             

 1.703        1.079 = 2.782

Veterans’ benefits/Total Costs %            39           79           30                42      

Personnel8,744.0002,225.0002,100.000

Killed     58.200         383      5.376

Wounded  153.303         467     39.900

Surviving8,685.0002,223.000 2,094.000

Table 3 shows the calculation of costs of four wars (in Vietnam, the Gulf, Iraq, and Afghanistan) waged by the U.S. in the last half of the twentieth century (Edwards 2012:16, table 2; Cost of War 2015:1). The direct military spending and long-term expenditures to veterans´ care differs from one war to another. The short First Gulf War has the lowest direct military costs in absolute and relative figures of all of the U.S.´s wars in the 20th century, but the highest costs of veterans´ care of 79 percent of all total expenditures. The highest direct military spending of the four wars (of all the 12 U.S wars from 1775 – 2014) has been the two wars in Iraq and Afghanistan with of $ 1,559 trillion already spent according to Edwards and $ 1.591 trillion according to Cost of War. These figures include the statistical life value of $ 4,8 – 7,2 million and disability value of between 30 to 50 %, in average, of statistical life value. The calculations of total direct military spending of $ 2,782 trillion to total veterans´ cost of $ 1,160 trillion gives 42 percent. Here, almost half of the total costs take place decades after the end of the war. For all twelve U.S. wars it can be concluded that “thirty years after the end of hostilities, typically half of all benefits remain to be paid” (Edwards 2012:54). Thus, “the peak year for paying veterans disability compensation to World War I veterans was 1969…for World War II veterans 1982…(while) payments to Vietnam and the first Gulf War veterans are still climbing” (Bilmes 2011:7). 

The third issue is the proportion of PTSD veteran care cost to the total care cost for all veteran beneficiaries. More studies have pursued the federal cost of only PTSD veterans offered by the Department of Veteran Affairs even if it is difficult to isolate PTSD veterans from other veterans with mental disorder as a PTSD suffer often will experience multiple types of mental diseases. Nevertheless, it is argued that PTSD is probably the single most common and costly of them. At least in the US: “According to US Department of Veteran Affairs, PTSD is the most common mental health diagnosis (21,5 %) among veterans, and based on current deployment rates, health care providers anticipate an annual expense of US $200 million on PTSD care” (Osei-Boamah et al 2013:2). “Out of U.S. $ 3.8 billion awarded as a result of U. S. Congressional funding bill HR2638 to the U.S. Veterans Administration (VA) in 2009 mental illness, the single largest mental disease category funded was PTSD…The first year of this health care cost was $ 1.4 billion (U.S. Congressional Budget Office 2012)” (Barglow 2012:1).

The U.S. Department of Veteran Affairs operates with four budget categories offered VA veterans: Medical, social security, disability, and other costs, from 2004 to 2053, cf. table 4. 

Table 4 in here 

Table 4. Total Federal Costs for the U.S. Department of Veteran Affairs.               

             2004 - 2053

Committee et al. (2007:1-2)

2004Dept. of Veteran Affairs (2014)

Institute of Medicine (2014:2)

   2012Bilmes 

(2011:4, table 2)

2012 - 2053Crawford 

(2014:7 - 11, table 3 -5) 

2001 –2014        2015 – 2053

All cost BN $-

           -       - 3.375    79

Total VA costs BN $65,1  142,8589 –   934   160  836 – 1.000

   VA Medical28,1    56201 –   348

     28  288

  Social Security 

      - 33 -      52      5    42

  VA   Disability 

29,8    63,6355 –  534     41  420

 + VA Other costs

  7,2    23,2         -     86   86 

VA costs 2001-2014/

All Costs 2001-2014       5 %

VA costs 2015-2053/

All Costs 2015-2053  26 %

Table 4 presents five perspectives on total care cost for the Department of Veteran Affairs, VA. In 2004, VA used $ 65 billion and the medical and disability budget post equaled eachother with $ 28,1 to $ 29,8 billion. In 2012 and for the period 2001 – 2014, disability cost (compensation and pension) increased the most and is expected to do so in the years to come towards 2053. Bilmes figures (2012 – 2053) are built on Stiglitz and Bilmes (2008). They wanted to find the war´s true cost, i.e. both government cost (military operations, demobilization cost, VA, disability payments, and futurer spending) and societal cost (local community cost, cost of reserve personnel, cost of fatalities, loss due to TBI and other injuries) and all of them to the “last man standing.” They reached a result of the total cost for the Iraq war alone to be at 3 trillion. Later, they estimated the long-term cost of providing medical care and paying disability compensation for veterans of the Iraq and Afghanistan wars and identified a total care amount in the range between $ 400 billion and $ 700 billion. This figure is now expected to be between $ 589 billion and $ 934 billion …due to higher claims activity and higher medical utilization…following the pattern of Vietnam veterans, where it is estimated that 30 % suffered from PTSD” (Bilmes 2011:3). The Crawford figures for 2001 – 2014 are based on Bilmes and for 2015 – 2053, the costs are, as shown, estimated to grow ten times, except for “VA Other Costs.” These cost “directly relates to…Mental health/PTSD” among other categories (Crawford 2014:7, note 26 based on Bilmes 2013). It is interesting that these PTSD costs do not increase. 

The cost of PTSD veterans exceeds those offered the average VA veteran according to a number of studies. “The number of beneficiaries receiving compensation for PTSD (has) incresed significantly during FY 1999 – 2004, growing by 79,5 percent, from 120.265 to 215.871 cases….(however their) benefits payment (has) increased 148,8 percent from $ 1,72 billion to $ 4,28 billion  in the same period” (Committee 2007:2). For the period 2012 – 2052, PTSD costs will increase, as well: “The incidence of PTSD is likely to increase the long-term medical cost beyond the level of previous conflicts…taking all these costs into account, the total budgetary costs associated with providing for America´s war veteran from Iraq and Afghanistan is likely to approach $ 1 trillion” (Bilmes 2011:5). In 2012, an analysis calculated that the total cost for the first four years of treatment offered by Veteran Health Administration, VHA, to all the 496.800 veterans at that time amounted $ 3,7 billion of which the 130.100 PTSD sufferers plus 8.700 with TBI took 60 % or 2,2 billion, while the 358.000 other treated veterans did only cost 1,5 billion or 40 % (Congressional Budget Office 2012: 1 + table VII). A 2015-study found that “PTSD (has been)…diagnosed in nearly one-fifth of veterans of OEF/OIF/OND” (i.e. from Iraq, Afghanistan, and Pakistan) (Finley et al. 2015:73). In short, “PTSD has one of the highest cost to treat any disorder” (Market Watch 2014:1).  

The expected increase in PTSD costs are based on more factors. First, the increase of the PTSD group as such: “Studies of the prevalence of PTSD among OEF/OIF (i.e. Iraq and Afghanistan) VA users consistenly show a rise  over time” (Shiner 2011:1); “At least 20 % of Iraq and Afghanistan veterans have PTSD and/or depression…while interviewed 20-25 years after Vietnam …four out of five Vietnam veterans struggled with cronic PTSD symptoms” (Veteran PTSD Statistics 20015:1). Second, the over-consumption of PTSD users: “The body of literature on VA services use among OEF/OIF Veterans has documented a high level of service use and a high rate of PTSD among service users” (Shiner 2011:3); “Veterans with PTSD consumed almost twice as much general health care as those without a mental health diagnosis” (Shiner 2011:1). Third, the level of medical activity of PTSD veterans compared to other VA enrolled clients: Veterans with PTSD from Iraq and Afghanistan completed more mental health visits and were less likely to drop out of treatment as other VA-care outpatients (Schiner 2011) based on the examination of 30 studies of the utilization of VA Health service. Consequently, PTSD veterans have a higher user-rate than the average VA service user. Fourth, the level of consumption of the PTSD group decreases more slowly than that of other VA veterans users: The “continuation of use of VHA´s Services by OCO (Iraq and Afghanistan) veterans” show a drop to only 80 % for PTSD veterans…(but) for others to 40 % (Congress Budget Office 2012:14, fig. 1). 

This domination of PTSD users to other VA beneficiaries have more explanations. One is military. It is related the asymmetric type of warfare in which soldiers are deployed. “PTSD might be a common form for psychiatric casualty in “low-level” warfare” (Crocq & Crocq 2000:53) and as many as “a third of the veterans returning from Afghanistan and Iraq are currently affected by PTSD or depression or….TBI while deployed” (Tanielian et al. 2008:435). In 2005, 100.000 veterans were treated by the Veteran Affairs out of 500.000 veterans. In 2010, the number of treated veterans has grown to 500.000 out of 1,300.000 deployed servicemembers (Congress Budget Office 2012:1). Thus, the number of deployed soldiers in asymmetric warfare positions went up with 20 %, the number of treated veterans by 31 %. This explanation of the asymmetric warfare goes along with the findings that UK veterans with conflict/combat experience enjoy more benefits than veterans without such experience (Dandeker et al. 2006).

Another is economic. A postponed help from VA increases its future cost: “Literature clearly documents that there are long-term negative repercussions of having these conditions (PTSD, major depression, and TBI) if they remain untreated “(Tanielian et al. 2008:437); “Among those who met the diagnostic criteria for PTSD and major depression, only 53 percent… seek …help…in the past twelve months” (Tanielian et al. 2008:435) and “of 1.2 million service members eligible for VA services, only 600.000 have used the VA health service” (Schiner 2011:1). 

A third is organizational. The armed forces organization creates PTSD when it for more than a decade have been on the alert to meet the political demands of deploying soldiers abroad. “Between 2004 and 2012, the percentage of all active duty members with a diagnosis of PTSD increased from 1 to 5 percent” (Institute of Medicine 2014: 1f). 

A fourth is psychological. The individual soldiers may fear or wish for deployment abroad. Both feelings may initiate PTSD. Another psychological factor to create PTSD is the contending roles of the veteran depending on the right to and use of VA care, cf. table 5 below: 

Table 5 in here

Table 5. Four Roles of a PTSD Veteran Based on the Presence/Absence of 

             Being a VA User – VA Qualified   

                              VA user

               -                                          +

VA  qualified  

               -

               +Hero

(honor, prestige, positions, 

political recognized)Stigmatized

(lazy, looser, ashamed, dishonoured, useless) 

 Entitled

(social rights, job, marriage,

grateful children, friends)Victim

(empathy, pity, love, support, loyalty, respect, comradeship)

Table 5 is a matrix placing a PTSD veteran in four different position as either a hero (neither right to nor receiver of VA care), entitled (right to but no user of VA care), stigmatized (no right to, but receiver of VA care), and finally victim (right to and receiver of VA care). It is easy to imagine the stress for any veteran to move from one of the two positive boxes at left to either of the two boxes to the right. In particular, it adds to the mental disorder of any PTSD veteran to be misplaced by society, comrades, and family. A fifth is medical. “The majority of people with PTSD have three other disorders (depression, anxiety, substance abuse)” (Market Watch 2014:2). Whatever the reason, PTSD creates many victims, has more contributors but no single responsible actor. Societies feel obliged to assist. From the point of social responsibility, not from the position in a court as the guilty defendant. 

Conclusion

PTSD is not a disease, but a historically and culturally variable latent disorder, that may be activated by the veteran´s memory of the incident and own self-perception and other peoples´ behaviour that create a variety of diseases. It is documented by the different perceptions of the concept (the process model, fig. 1, vs. the biomarker model, fig. 2), content (the five DSM versions), chronology (the many names over time for PTSD and the absence of names), contributors (personal and military), consequences (illness and social inability), coping (medicine or cognitive consultations), and cost (what type of expenses should be included and how). One crucial may be raised: How can it be argued that PTSD has existed throughout history, when each war/violence is different. One answer is: “Every war is different. Every time there is a war, different social attitudes to fundamental questions like fear, madness and social obligation will redefine the role of military psychiatry in a different way. Medicine will be different; and symptoms; so, too, will military and institutional circumstances. (Shephard, 2002: p. xxii). The answer here is that society define PTSD and PTSD define society, medicine, military psychiatry, etc. But, it is no explanation, only a relation. Another answer to the question is: “I will argue that this generally accepted picture of PTSD, and the traumatic memory that underlies it, is mistaken. The disorder is not timeless, nor does it possess an intrinsic unity. Rather, it is glued together by the practices, technologies, and narratives with which it is diagnosed, studied, treated, and represented and by the various interests, institutions, and moral arguments that mobilized these efforts and resources.” (Young 1995:6). This answer operates with a “timeless” PTSD that is “glued together.” How can it be moveable and at the same time “glued” and what makes it be one or the other? A third answer is that PTSD is a more profound and previous element in the lives of human beings than war/violence. It is a human tool of preparedness and survival. It exists before the traumatic event. PTSD is an activated latent stress phenomenon ignited by traumatic events. Thus, its proper name should be Activated Post-Traumatic Stress Disorder, APTSD.    

Henning Sørensen & Claus Kold

Abbreviation

APA, American Psychiatric Associciation

CBT, cognitive-behavioural therapy

CPT, cognitive processing therapy

CSR, combat stress reaction

DAH, disordered action of the heart 

DSM, Diagnostic and Statistical Manual of mental disorder of the American

        Psychiatric Association, respective years

DoD, U.S. Department of Defence

NIMH, National Institute for Mental Health

OCO, Overseas Contingency Operations

OEF, Operation Enduring Freedom (in Afghanistan)

OIF, Operation Iraqi Freedom

OND, Operation New Dawn (in Iraq after August 2010)

PCL, PTSD Check List (17 item self-reported checklist)

PE, prolonged exposure therapy

PTSD, post-traumatic stress disorder

RCoD, research domain criteria

SCID, Severe Combined Immune Deficiency

TBI, traumatic brain injury

VA, Department of Veteran Affairs

VHA, Veteran Health Administration

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