A Rose by Any Other Name: PTSD and Combat Stress

We Are the 0.001%

When you hear the word “veteran,” what do you immediately associate with that word? For many people, unfortunately, they think PTSD. Not honor, sacrifice, discipline, selflessness, leadership…but a psychiatric disorder. Why? Statistics say that 20% of veterans who served in Iraq and Afghanistan report suffering from PTSD—that’s nearly 500,000 veterans. But less than 270,000 troops deployed to Afghanistan and Iraq in direct combat roles, according to my math (see below). The number of troops who saw sustained combat? Less than that.

This is problematic in many ways. If we assume that 100% of troops who see combat suffer from PTSD, this number only accounts for 25% of the total number of veterans dealing with PTSD. If we assume that 20% of troops who see combat develop PTSD, then combat veterans only account for 10% of the whole. If that is the case, we have to throw out the case of war or combat being traumatic by its nature, which by any examination is inherently untrue, unless you think little pieces of hot lead flying toward your face at 3000 feet per second is casual. Perhaps we have a slew of veterans who don’t want the stigma of PTSD, it harms by its namesake: if you go to combat and it changes you, you are disordered.

But combat does affect those who partake in it, every single one of them. PTSD can happen to combat veterans, because traumatizing things happen while at war. But what combat veterans experience while re-adapting to civilian life is just plain different. I believe we need a diagnosis for combat veterans and the specific types of stress they experience. I’m calling it Persistent Adaptive Combat Stress, or PACS. It is simply the persistence of adaptations to combat stress that the individual has undergone, through necessity or cultivation, which persist due to their actual or perceived effectiveness to the individual’s survival.

“You bring me back to the philosophers, who seldom go to war.”

—Cicero, Tuscan Disputations

The Numbers

There are 182,700 active duty Marines this year, though only 17,000 or so have an infantry MOS (job), and for the sake of argument this number includes Scout/Snipers, Critical Skills Operators, and Reconnaissance Marines. Direct combat forces makeup less than 10% of the Marine Corps. The US Army numbers 490,000 and has about 40,000 infantry. Add in your Navy SEALs, PJs, and various other elements of SOF and maybe we hit 60,000 total. Maybe.

The Department of Defense’s budget for 2015 includes pay for 1.3 million troops. Only 60,000 have a job where they are expected to conduct ground combat operations. That means that 4.4% of the armed forces are gunslingers. According to the 2010 Census, there were 60,000,000 males fit for military service. And 60,000 of them have military combat jobs. That’s 0.001%.

It’s a stretch to believe that each and every soldier or Marine with a combat MOS actually sees combat, as the nature of counterinsurgency is distributive, unpredictable, and asymmetric. Regardless, we do know that there are 2.7 million veterans of the Iraq and Afghanistan Wars. It’s safe to assume that the combat operations element consists of roughly 10% troop strength, giving us 270,000 veterans who deployed in a direct combat capacity. To assume that every one of these veterans saw combat is a stretch of the imagination. And as far as combat goes, a couple of potshots warrants recognition on your record the same as a 6-day sustained firefight. The number of troops who were in prolonged and sustained combat operations? Maybe it’s down to 200,000 now.

Shell Shock. Combat Fatigue.

Combat is the pinnacle of achievement for the warrior, the place where his mettle is tested, where his training comes to fruition, where fear and courage are finally experienced in full and understood to be two sides of the same coin. According to Fleet Marine Force Manual 1, Warfighting, the “essence of war is a violent struggle between two hostile, independent, and irreconcilable wills, each trying to impose itself on the other.”

Since the earliest human writings we have evidence of combat’s effect on the human psyche:

  • Consider the story of Epizelos, written by Herodotus after the Battle for Athens in 490 BCE; 2,505 years ago: “Epizelus, the son of Cuphagoras, an Athenian, was in the thick of the fray, and behaving himself as a brave man should, when suddenly he was stricken with blindness, without blow of sword or dart; and this blindness continued thenceforth during the whole of his after life.”
  • Cicero wrote in 109 BCE: “What about when your warrior’s anger goes home? What is it like with his wife and children? Is it useful then, too?”
  • During the Napoleonic wars, nostalgia was a disease, and a serious one at that. Dr. Johannes Hofer coined the term “nostalgia” to refer to  ‘homesickness,’ a condition that afflicted Swiss troops on the front lines, to include depression, listlessness, and suicide.
  • In the American Civil War ‘insanity’ and ‘nostalgia’ were common maladies. Technological advances in weaponry make war much more violent.
  • During WWI, we get our first signs of Traumatic Brain Injury, as “shell shock.”
  • Marines call it the “thousand-yard stare.” In recent times it’s been called the two- or ten-thousand yard stare as volunteer troops serve four, five, six, or more combat deployments back-to-back.

Traumatic brain injury

We also know that Traumatic Brain Injury, or TBI, is often co-morbid with diagnosis of PTSD, and they have overlapping symptoms. According to French and Parkinson (2008), (emphasis mine) “The highly stressful and dangerous context in which these injuries are sustained set them apart in significant ways from brain injuries seen in civilian settings. The associated emotional toll of the environment and co-morbid injuries, often resulting from blast exposure, complicates the clinical picture.”

Indeed it does, when large scale artillery came into common usage across militaries in WWI, it is then that we discovered “shell shock.”

The scientific literature already shows that war trauma is set apart from the types of trauma experienced by civilians, and it’s time for change.

Post-Traumatic Stress is what happens after a car accident. A rape. A home invasion or an armed robbery. an event happens that leaves an indelible impression, psychologically and emotionally. An outlier event, something unexpected that injures a person down to their soul. Combat has these events, sure. But the nature of life in combat itself has deeper, more insidious effects.

In Iraq and Afghanistan, the ground beneath your feet was very often the enemy. Every step you took could be your last. Even the language of the sky turn violent. Steel rain, we call it. When mortars and rockets fall out of the sky and shoot red-hot shards of metal. The very people you interact with are turned lethal with your first encounter with a suicide bomber. Everyone is suspect. While on patrol you keep your distance from each other, even your best friend, because clumping together invites an attack. You’ve been spooning your rifle every night and realize that after three years, it’s the longest and most intimate relationship you’ve ever had.

Every time you look at your boots, you see that splotch of blood that reminds you of that one day.

Then the constant exposure to IED blasts, suicide vests, hand grenades, incoming mortar attacks.  TBI is the signature injury of the Iraq and Afghanistan Wars, primarily because of advances in body armor and battlefield medicine. Blast related injury is extremely common, and in many cases, troops were not diagnosed on the battlefield or medivac’d because of the necessity of having another rifle in the fight.

Psychiatrists hardly ever go to war

The truth of the matter is when it comes to matters of war, the public rarely listens to the experts: those who fought it. When we talk about climate science, we defer to the experts and cite scientific studies. In feminist circles, men give deference to women’s experience. When veterans talk of their experiences, we think of Post-Traumatic Stress Disorder. Listen to that last word.

What does it do to someone when you call them disordered because they did their job? That doesn’t honor the pain they went through. That WE went through. You wouldn’t accuse a veteran with an amputated leg of being disordered because he can’t run a mile as fast as he used to.

Dr. Jonathan Shay, VA Psychiatrist, has always been at odds with the term ‘post-traumatic stress disorder’, because “we are dealing with, essentially, an injury, not an illness, disease, sickness, or disorder.” What is consistently called PTSD is rather the persistence of adaptive combat skills which were honed to perfection due to the necessity of their use for survival. Let’s look over the list of PTSD symptoms and apply this new framework, replacing the word ‘trauma’ with war:

  • Emotional numbness: useful on the battlefield when someone close to you is wounded or killed, and you must continue the mission.
  • Re-experiencing the war (traumatic event): like an instant replay at a sports game, trying to find every detail of what went wrong, what you could’ve done better, always seeking improvement.
  • Increased anxiety and emotional arousal: there are people out there hiding in the civilian populace who are trying to kill you every single day. A little increased anxiety and arousal should be expected.
  • Avoiding places that remind you of the war: open areas, sniper locations, possible IEDs, ambush locations, exfil spots, cover and concealment, all things going on the mind of a warrior while on deployment. These scenarios continue to play in a warrior’s head long after leaving combat, due to the importance of them to the warrior’s survival.

All of these symptoms can simply be seen as adaptations to combat stress. The issues that many combat veterans face are dropping the habits of hyper-vigilance and always being on alert. This isn’t the movies for them, it’s real life. And habits that have saved that life don’t just turn off because you talk to a therapist for a couple of hours.

It’s Time to Take Action

I’m gathering support to have Persistent Adaptive Combat Stress officially recognized by the Veterans Administration as a combat related injury separate from PTSD and TBI. You can do your part by sharing this story, and by sharing this blog post and our petition on Whitehouse.Gov. In the near future, we’ll be drafting a form letter you can send to your congressional representatives in support of this new measure.

Honor the struggle that our warriors go through. 1 out of 1,000 men in this country are combat veterans. So many people ask me what they can do to help. Support this measure!

Here are the links:

WhiteHouse.Gov Petition: We the People petition the Obama Administration to have VA recognize Persistent Adaptive Combat Stress as a combat-related injury separate from Post-Traumatic Stress Disorder.

web: https://petitions.whitehouse.gov//petition/have-va-recognize-persistent-adaptive-combat-stress-combat-specific-injury-separate-ptsd

shortlink: http://wh.gov/iW61H

We’ve got one month to gain 100,000 signatures to force the White House to respond to this issue. Time to sign and support. Please.