Combat PTSD (Post-Traumatic Stress Disorder)

Introduction to Combat PTSD

Hurricane Katrina ravages the Gulf Coast in 2005, and an earthquake savages Pakistan, India and Afghanistan. In 2004, a crushing tsunami rises out of the Indian Ocean. A terrorist attack paralyzes a nation on a mid-September morning in 2001. Every two minutes, an American is raped.¹  Over 6 million are involved in car accidents annually.²  One to 3 million are victims of domestic violence every year.³  And some are sent to combat.

Trauma and disaster are part of the human experience. Statistically, 50 percent of us can expect to survive at least one traumatic event over the course of our lives.⁴

As animals, we have a built-in ability to adapt to our changing environment and to the stresses and circumstances of life. Our adaptability acts as protection. After a traumatic event, it is natural to experience stress and preoccupation with the event. Though it may not feel “normal” at the time, replaying the episode is our brain's way of processing, modifying and integrating the brutal incident before moving on.⁵

Unlike combat stress disorder, which is an immediate response to events taking place on the battlefield, post-traumatic stress disorder develops over time. Richard Pierce, a Vietnam veteran who has been a tireless advocate for returning combat veterans, describes the build-up of PTSD: “In its initial stages I think the nightmares, withdrawal, and anxiety are natural defensive reactions to a very traumatic experience. At this early stage it’s like a toothache, painful and troubling. Left untreated, the infection festers and grows. That’s when it becomes an illness.”⁶

PTSD leaves an unpleasant impression on the mind, like a scratch on an old vinyl record, which can cause permanent damage over time. Dr. Edward Tick, a clinical psychotherapist with extensive experience treating veterans and author of War and the Soul: Healing Our Nation's Veterans from Post-Traumatic Stress Disorder, refers to combat PTSD as “frozen war consciousness.”⁷

Time appears to stand still as the trauma survivor skips back repeatedly to the event through intrusive thoughts, nightmares, and other triggers. Each re-experience leaves the sufferer mentally and physically drained, and their anxiety and frustration increases as they continually feel out of control. Avoidance or rage may result along with any number of other symptoms and reactions.

Symptoms and Reactions

Following a stint in a war zone, veterans return home changed.

While many are strengthened by the challenges of combat, others return with a changed view of themselves and the world around them. For some, reactions to their experiences may be short-lived (perhaps lasting the first few months of reintegration back into civilian life). For others, healing may require long-term vigilance and care (lasting months, years and even decades).

Typical symptoms of combat-related PTSD (in no particular order, with additional symptoms to follow):

• Survivor guilt
• Cynicism
• Frustration
• Fear
• Negative self-image
• Problems with intimacy
• Distrust
• Loneliness
• Suicidal feelings
• Preoccupation with thoughts of the enemy
• Revenge fantasies
• Addiction
• Alcoholism
• Thinking that feelings are meaningless
• Feeling powerless or hopeless
  
• Resignation (“don’t care”)

The above list includes only a small portion of the symptoms that may be found in a veteran coping with PTSD. Additional symptoms or groups of problems are shown below.

In 2000, the American Psychiatric Association revised the PTSD diagnostic criteria in its fourth update of what is considered the 'Bible' of psychiatry, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR).

To receive a PTSD diagnosis, a person must be “exposed to a traumatic event” and confronted with “actual or threatened death or serious injury, or a threat to the physical integrity of self or others.” Their response would have “involved intense fear, helplessness, or horror” at the time.

PTSD requires that a month after the event they’re still experiencing flashbacks, having nightmares, emotionally and/or physically responding to certain triggers, actively avoiding thoughts and feelings or discussions or people or places that remind them of the trauma, feeling ‘pumped up’ or not able to relax, getting angry easily, etc. All of these symptoms would combine in the patient, affecting their ability to function in social and employment situations. These reactions to trauma would fall under three symptom clusters as outlined below: intrusive recollections, avoidant/numbing symptoms, and hyper-arousal symptoms.⁸

Intrusive - Re-experiencing of the traumatic event(s)

• Distressing recollections

• Flashbacks (feeling as if you're back in combat while awake)
• Nightmares (frequent recurrent combat images or other frightening themes while asleep)
• Becoming upset when reminded of the incident
  
• Feeling anxious or fearful (as if you're back in the combat zone again)

Because trauma survivors have these upsetting feelings when they feel stress or are reminded of their trauma, they often act as if they are in danger again. They might get overly concerned about staying safe in situations that are not truly dangerous. For example, a person living in a safe neighborhood might still feel that he has to have an alarm system, double locks on the door, a locked fence, and a guard dog. Because traumatized people often feel like they are in danger even when they are not, they may be overly aggressive and lash out to protect themselves when there is no need. For example, a person who was attacked might be quick to yell at or hit someone who seems to be threatening.

Re-experiencing symptoms are a sign that the body and mind are actively struggling to cope with the traumatic experience. These symptoms are automatic, learned responses to trauma reminders. The trauma has become associated with many things so that when the person experiences these things, he or she is reminded of the trauma and feels that he or she is in danger again. It is also possible that re-experiencing symptoms are actually a part of the mind's attempt to make sense of what has happened.

Avoidant - Drawing inward or becoming emotionally numb

• Extensive and active avoidance of activities, places, thoughts, feelings, memories, people, or conversations related to or that remind you of your combat experiences

• Depression and/or loss of interest
• Feeling detached from others (finding it hard to have loving feelings or experiencing any strong emotions)
• Feeling alienated, disconnected from the world around you and things that happen to you
• Feeling betrayed by God and/or society (cast off)
• Restricting your emotions
• Trouble remembering important parts of what happened during the trauma
• Shutting down (feeling emotionally and/or physically numb)
• Things around you seem strange or unreal
• Feeling strange and/or experiencing weird physical sensations
• Not feeling pain or other sensations

Because thinking about the trauma and feeling as if you are in danger is upsetting, people who have been through traumas often try to avoid reminders of the trauma.

Sometimes survivors are aware that they are avoiding reminders, but other times survivors do not realize that their behavior is motivated by the need to avoid reminders of the trauma. Trying to avoid thinking about the trauma and avoiding treatment for trauma-related problems may keep a person from feeling upset in the short term, but avoiding treatment means that in the long term, trauma symptoms will persist.

Hyperarousal - Increased physical or emotional arousal

• Difficulty sleeping

• Irritability or outbursts of anger
• Difficulty concentrating or thinking clearly
  
• An exaggerated startle response (triggers bring you back to a certain combat zone event)
• Hypervigilence, being overly angry or aggressive (feeling as if you need to defend yourself from danger, i.e. unrelenting survival mode stance)
• Panic attacks

Triggers can include any of the following:

• Specific scenes - crowded streets, sunsets, sunrises, familiar clothing
• Movement - someone rushing towards the individual
• TV - even if the story is unreal, the subject or the environment may cause thoughts which act as a trigger
• Sound - helicopters, songs, unexpected loud noises
• Smell - jungle or bush, rain, smoke, blood, cordite or explosives
• Reading - or discussion about subjects of trauma
• Touch - gun metal, webbing, blood
• Situational - being crowded, walking across open spaces, feeling vulnerable or not in control

With every trigger and re-experience, depressive emotional and biological patterns or habits are set down. Modern psychology calls these patterns neural grooves. Eventually, people coping with PTSD begin “organizing their lives around the trauma.” Their work, their family relationships, and their long-term health usually suffer as a result.

It is important to note that being subjected to combat trauma does not automatically mean one will suffer from PTSD. Early intervention is key. Setting constructive and positive responses to triggers in the early stages increases the likelihood that the trauma reaction can be defused. Yet even with vigilance and all the right supports in place, the invisible scars of war can haunt a warrior for a lifetime.

One Vietnam Veteran's Experience

On February 4, 2005, Alan McLean, a Purple Heart and Bronze Star Vietnam veteran and popular rector at St. Luke’s Episcopal Church in Wenatchee, Washington, composed a letter to his wife and kids on his laptop. In the message, he apologized to them for not being stronger, explaining that the war in Iraq had made his nightmares about Vietnam more powerful and painful. The former Marine second lieutenant added,“ 35 Marines died today in Iraq, [a loss] only slightly more noticed than my legs,” referring to the strong limbs a landmine had taken from him thirty-eight years before.⁹

Initially, McLean had been supportive of the Iraq War, as he was of the war in Afghanistan, delivering a sermon on the need to have faith in the government’s mission. Six months later, as the war reports extracted their heavy toll on the conflict-ravaged minister, he delivered an opposing sermon to the small farming community that he ministered over. As flashbacks and panic attacks progressively destroyed what little peace he had managed to create for himself following Vietnam, he turned a pistol towards his chest in his church office on February 11, 2005 and escaped the war-torn earth. His daughter would later say, “I underestimated the power of the war to take his life. And I really feel that, though my dad’s been in Wenatchee, the war in Iraq killed him.” ¹⁰

History of Combat PTSD

Though it has been referred to by a number of different names, post-traumatic stress disorder has been with us for as long as wars have been fought. The Greek historian Herodotus, writing of the battle of Marathon in 490 BC, mentions an Athenian warrior who went blind when the soldier standing next to him was killed, although the blinded soldier “was wounded in no part of his body.” Herodotus also wrote of the Spartan commander Leonidas, who, at the battle of Thermopylae Pass in 480 BC, dismissed his men from combat because he recognized they were mentally exhausted from previous battles.¹¹

However, post-traumatic reactions were not exclusively reserved for those who fought in battle. Having survived the Great Fire of London in 1666, Samuel Pepys recorded in his diary the frightened, angry, and disturbed moods that haunted him for the next several months, even though he had been uninjured in the fire and his house undamaged.¹²

It wasn’t until 1678 that a name was given to the symptoms that made up post-traumatic stress, when Swiss physician Johannes Hofer coined the term “nostalgia.” Initially called the “Swiss disease” because of its prevalence among Swiss men who fought in mercenary armies, nostalgia was characterized by “melancholy, incessant thinking of home, disturbed sleep or insomnia, weakness, loss of appetite, anxiety, cardiac palpitations, stupor, and fever.”¹³ Around the same time as Hofer’s diagnosis, German, French and Spanish doctors noted similar symptoms in their combat troops.

During the Napoleonic era, French physicians developed [pdf] a very advanced and modern understanding of the factors that lead to nostalgia, citing conditions ranging from the social to the environmental. Dominique Jean Larrey, Napoleon’s chief surgeon, prescribed a course of treatment that while biologically-based, took social factors heavily into account and was in many ways a precursor to our contemporary understanding of the psychiatric effects of warfare upon soldiers.¹⁴

The Civil War

The American Civil War saw a significant rise in the number of soldiers who suffered from battle-related psychological trauma. During the war years, the Union Army recognized [pdf] over 2,600 cases of insanity and 5,200 cases of nostalgia.¹⁵ In addition to the official cases, many “insane” Union soldiers were simply discharged and left to find their own way home. The public outcry that resulted over this led [pdf] to an 1864 War Department order requiring that such soldiers be transferred to the Government Hospital until their families could retrieve them.¹⁶

Desertion by psychologically traumatized soldiers was also a problem. Those unable to fight were labeled “malingerers” or “cowards,” and many soldiers deserted instead of risking being tagged with one of these labels. However, no matter which options a combat-stressed soldier chose, the penalty was brutal: malingerers, cowards and deserters were executed by firing squad while their fellow soldiers were forced to watch. Everyone got the message of what happened to those who were no longer willing to fight.¹⁷

In 1871, an internist named Jacob Mendez Da Costa wrote [pdf] of the chest-thumping anxiety and breathlessness he had observed in many soldiers on the front during his time as a Union doctor. The main symptoms of “the irritable heart of the soldier,” or DaCosta’s Syndrome as it became to be called, were a persistent tachycardia, or “hyper-arousal,” which led to anxiety and hyperventilation.¹⁸

While Americans waged civil war, Great Britain was mired in an internal conflict of another kind. A number of deadly and highly publicized train accidents had rocked the nation, creating a trauma condition called “railway (or railroad) spine.” First noted by an English surgeon in 1867, railway spine was “characterized by the manifestation of a variety of physical disorders in otherwise healthy and apparently uninjured railway accident victims.” Attention to this new industrial age disorder spurred many in the medical profession to examine the role of psychological factors in “provoking” physical disorders.¹⁹

World War I

The first organized military system for psychological treatment of combat fatigue occurred [pdf] during the Russo-Japanese War (1904–1906), when physicians were put as close to the front as possible to allow them to perform evaluations of traumatized soldiers.²⁰ This “forward treatment” recognized the value of caring for psychological casualties as quickly and as close to the action as possible. The point was to keep the traumatized GI near his unit, as it was observed that the farther from the point of battle that a soldier traveled, the less successful doctors were in getting him back in the fight.

World War I ushered in a whole new type of warfare, as modern weaponry inflicted a brutal toll on the flesh and mind. Captain F. C. Hitchcock, a British officer, reflected on this vicious new and violent form of warfare:


The “bitterness” that Captain Hitchcock recorded reflected the circumstances of the new modernized form of combat, as the idea of fairness or control over one’s destiny was blasted into oblivion by the magazine rifle, the machinegun and the quick firing artillery piece. As a result, a new term was adopted to describe psychologically traumatized soldiers: “shell shock.”

Soldiers who suffered from this condition literally acted as if they had sustained a shock to their central nervous system, often suffering from “staring eyes, violent tremors . . . and blue, cold extremities.” In addition, many shell-shocked soldiers became [pdf] deaf, blind, or paralyzed, even though they were physically uninjured.²²

To treat shell shock, British and French psychiatrists expanded on the work of their Russian counterparts from the Russo-Japanese War, making forward treatment an integral part of the treatment process. In 1917, Thomas Salmon of the U.S. Army Surgeon General’s office built upon the work of the British and French to create the first comprehensive treatment program for shell shock, or “war neuroses” as it was renamed. Salmon’s system, which involved placing psychiatrists in combat units with forward hospitals to support them, centered around four key treatment principles, which are still the cornerstone for treating combat stress:

• Proximity (treating the soldier as close to the battle as possible)
• Immediacy (treating the soldier as soon as possible)
• Simplicity (providing simple treatment such as rest, a warm shower and food)
• Expectancy (the expectation that the solider will return to fight after he has been treated)²³

Despite the progress made in the psychological treatment of traumatized soldiers during World War I, many of the conclusions that the medical profession reached turned out to be flawed. For example, they still clung to the notion that only the “weak” succumbed to wartime strain, as well as holding fast to the idea that rigorous pre-enlistment screening could help to separate those likely to experience shell shock and battle fatigue from those who could withstand the rigors of combat.

World War II

[Larger version] "Three Lives Brightened by Deadly Nightshade"
Wyeth Pharmaceuticals placed this ad in Life Magazine on September 17, 1945, touting the benefits of their product in curing "battle reaction/mental trauma" caused by WWII...and colic. While it didn't turn out to be the cure-all they'd claimed, the marketing campaign is interesting because 1) it presents shell shock as a normal, if trying, after effect of war; 2) the practice of psychiatry is treated with respect and admiration; and 3) an interdisciplinary treatment approach for combat stress, with medication and counseling working together to return the soldier to full health, is employed. Could we imagine such an ad running today?


During the interwar years, the belief [pdf] that pre-enlistment screening could minimize combat trauma cases became so prevalent that, when World War II began, psychiatrists were no longer assigned to combat divisions, and no provisions were made for psychiatric treatment in the field.²⁴ As a result, many of the successful “forward treatment” lessons of World War I were forgotten.

Unfortunately, the screening process turned out to be a complete failure. Despite the fact that twelve percent of the fifteen million armed forces recruits during World War II were rejected due to psychiatric disorders (as compared to two percent during World War I), psychological casualties during World War II wound up being 2.4 times greater than in World War I.²⁵ Not only was the screening process ineffective, it also wound up hurting the war effort; midway through the war, more soldiers were being eliminated [pdf] from the army than were being allowed to join.²⁶

Despite the failure of the screening process, there were still important lessons learned about combat stress during World War II. One was that inexperienced troops were more likely to suffer breakdowns than seasoned soldiers. Another was that the threat of combat stress increased with the intensity of combat. Finally, and perhaps most importantly, it was learned [pdf] that group morale was a contributing factor in preventing war trauma, as units with strong cohesion and leadership had fewer combat stress casualties.²⁷

Korean War

The American military had still not corrected its deficiencies in treating combat stress when the Korean War began in 1950. As a result, initial trauma casualty rates were two and three times higher than during World War II. Rather than using the forward treatment techniques that had proven to be successful in earlier war efforts, psychological casualties were being evacuated from the combat zone, greatly harming their chances at recovery. As Peter J. Murphy wrote in Military Stress and Performance: The Australian Defence Force Experience, “lessons in the management of both the psychological casualties of combat and returning veterans have had to be repeatedly relearned, at great personal cost to service personnel affected by the stress of war.”²⁸

Fortunately, due mostly to the efforts of Colonel Albert J. Glass, the principles of forward treatment were quickly reinstated, reducing the number of psychiatric causalities. Other procedures were also implemented [pdf] in order to reduce combat trauma, including a rotation system for troops, and greater attempts to rest soldiers (rest and recreation or “R and R”).²⁹

Despite the overall success of combat psychiatry during the Korean War (approximately 90 percent of psychiatric casualties returned to battle), a new problem developed: the psychiatric problems of rear-area or rear-echelon troops. As the war progressed and support troops, who rarely found themselves in dangerous situations, came to outnumber those engaged in actual combat, psychological conditions similar to what had been seen in soldiers who had once suffered from nostalgia, including longing for home and friends and boredom, became prominent. To seek relief from these symptoms, many rear-echelon troops turned to alcohol and drugs, and sexual stimulation. Unfortunately, the problems of rear-echelon troops were for the most part ignored [pdf]; they would go on to become the dominant psychiatric casualties of the next major U.S. conflict, the Vietnam War.³⁰

Vietnam War

“We don’t promise you a rose garden.”—1971 Marine Corps recruitment poster

Because of the Vietnam War’s slow build-up, the psychological casualties didn’t show up as quickly as they had in previous wars, and when they did, they showed up at a much lower level than in past conflicts. The low levels of combat fatigue were attributed [pdf] to several factors, including the twelve-month rotation policy, the absence of sustained artillery fire and the lack of prolonged battles.³¹

However, it was in the aftermath of the war that the situation worsened, as veterans streamed into the Veterans Administration seeking help for trauma they were experiencing months and even years after their initial experiences on the battlefield. Dr. Matthew J. Friedman, who began a lengthy career in the VA in 1973, recalled how, “People were flooding the clinics, demanding that we do something for their distress. We had no clinical terminology for what we were seeing. Their suffering was so raw.”³²

One of the main barriers to treating veterans' psychological symptoms was a lack of consistent terminology for their ailments, as there had been at least eighty different names used for what was was essentially psychological trauma or combat stress since the syndrome had first been recorded.

These include, but are far from limited to, the following list of terms (in no particular order):


Much-needed relief from the cacophony of labels came when Dr. Robert Jay Lifton, a well-known research psychologist, used the term “post-Vietnam syndrome” at the Congressional Conference on War and National Responsibility in 1970. Dr. Lifton’s use of the term in his testimony was literally a defining moment in the treatment of combat stress.³⁴

 Partnering with Dr. Chaim F. Shatan, Lifton helped to add new focus and terminology to the combat psychology revolution. In 1980, their work, along with that of veterans, psychologists, and anti-war activists, succeeded in convincing the American Psychiatric Association to add a definition for “Post-Traumatic Stress Disorder” to the third edition of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM).

The DSM-I, published in 1950, had relied heavily on the input of World War II-era military psychiatrists for defining combat stress. Covering four pages, the text stated that “gross stress reactions” stemmed from either catastrophes or combat. In addition, its preface spoke of the “value of the stress definitions to military psychiatrists [and] psychiatrists working with veterans.” But ironically, all reference to such stress reactions was wiped completely from the DSM-II, published at the height of the Vietnam War in 1968.³⁵

With the publication of DSM-III, the oversight was remedied. An official name and definition once more in place, scientists and researchers were able to devote their energies to study the why’s of PTSD and finally leave the if behind.

Afghanistan and Iraq Wars

"I am so fucking scared of everything."
PostSecret is an online journal sharing postcards sent in from around the world containing secret regrets, hopes, experiences, fantasies, beliefs, and fears (to name but a few topics covered). On June 3, 2006, an anonymous Iraq veteran submitted the following, written on the back of a graduation invitation envelope: "At my best friend's graduation today, I heard a fire engine and could only think of a bomb going off, the F.D. responding. Firecrackers went off and I heard machinegun fire. When I drive in my car, as I look for oncoming traffic, I also check local buildings and houses for snipers. I have been out of the military for two years, and was only in Iraq for four months. I am so fucking scared, of everything."
 

The relative quiet of U.S. combat in the decades after the Vietnam War meant that the issue of post-traumatic stress disorder largely faded from public view. However, things changed quickly in 2002 and 2003, as the nation became involved in Afghanistan and Iraq. And, just as they had done in World War II, military planners disregarded the lessons of forward treatment, to fatal consequences.

The first sign that something was wrong occurred in 2002, when there was a rash of murder-suicides at Fort Bragg, North Carolina involving the killings of four military wives by their husbands, all recently returned Special Forces troops from Afghanistan. A year later, a wave of combat zone suicides in Iraq caused the Army to ask a team of doctors to determine whether the stress of combat and long deployments were contributing factors to their deaths.
As a result of this, in 2004, the Army and Marines launched Operational Stress Control programs, embedding mental health personnel within deployed combat divisions. Greg Gordon, a spokesman for the Marine’s Personal and Family Readiness Division, explained to a Washington Post reporter at the time that, “Before, we had to ship them out of the war theater. Now [the mental health professionals] can provide help immediately.”³⁶

As of April 2006, more than 230 mental health practitioners were treating frontline troops for the emotional (sadness, worry, fear), cognitive (disorientation, confusion, memory loss, inattention), and behavioral (aggression, suicidal) components of Combat Stress Disorder.³⁷ Mirroring the goals set forth in WWI, the overarching aim is to rapidly return troops to duty and reduce the manpower drain. The hope is that early treatment will also reduce the combat veteran’s long-term mental health problems and its associated costs.³⁸




This knol includes selections from the author's book, Moving a Nation to Care: Post-Traumatic Stress Disorder and America's Returning Troops (Ig Publishing, 2007).  © Ilona Meagher.

No part of the contents of this page may be used or reproduced in any manner without written permission of the publisher. For more on combat PTSD by this writer, please visit her online journal, PTSD Combat: Winning the War Within.

References

1. “Statistics,” Rape Abuse & Incest National Network
   
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4. Matthew J. Friedman, MD, PhD. Post Traumatic Stress Disorder: The Latest Assessment and Treatment Strategies, (Kansas City, Missouri: Compact Clinicals, 2003), 1.
5. Bessel A. Van der Kolk, Alexander C. McFarlane, and Lars Weisaeth, eds. Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society, (New York: The Guilford Press, 1996), 3–5
6. Richard Pierce, “Re: Update,” Email message to the author, March 30, 2006.
7. Edward Tick, War and the Soul: Healing Our Nation's Veterans from Post-Traumatic Stress Disorder, (Wheaton, Illinois: Quest Books), 99
8. Van der Kolk, McFarlane, and Weisaeth, Traumatic Stress, 6.
9. The 'Symptoms and Reactions' section is an author-compiled composite of PTSD symptom descriptions culled from the Journal of Clinical Psychology Expert Clinical Guidelines Series; the always informative National Center for PTSD website; and the Vietnam Veterans Association of Australia.
10. Mike Lewis, “Vietnam, Iraq wars cited for minister’s suicide,” Seattle Post-Intelligencer, February 22, 2005.
11. Ibid.
12. Steven Bentley, “A Short History of PTSD: From Thermopylae to Hue, Soldiers Have Always Had A Disturbing Reaction To War,” The VVA Veteran, March/April 2005.
13. Ibid.
14. Major Stephane Grenier, “Operational Stress Injuries (OSI): A New Way to Look at an Old Problem ,” Canadian Forces Support Personal Agency: Director of Military Family Services, June 12, 2005
    
15. Franklin D. Jones, M.D., F.A.P.A, “Psychiatric Lessons of War [pdf],” in War Psychiatry, The Textbooks of Military Medicine, ed. Brigadier General Russ Zajtchuk, M.C., (Washington, DC: Office of The Surgeon General, Department of the Army, 1995), 6.
16. Ibid, 8.
17. Nicolas L. Rock., M.D., F.A.P.A., James W. Stokes., M.D., Ronald J.Koshes, M.D., Joe Fagan M.D., William R.Cline, M.D., and Franklin D. Jones, M.D., F.A.P.A., “U.S. Army Combat Psychiatry [pdf],” in War Psychiatry, The Textbooks of Military Medicine, ed...
18. Penny Coleman, Flashback: Posttraumatic Stress Disorder, Suicide, and the Lessons of War. (Boston: Beacon Press, 2006), 23–24.
19. 18. “U.S. Army Combat Psychiatry [pdf],” War Psychiatry, 153.
20. Ralph Harrington, ‘The Railway Accident: Trains, Trauma and Technological Crisis In Nineteenth Century Britain,” in Traumatic Pasts: History and Trauma in the Modern Age, ed. Mark S. Micale and Paul Lerner, (Cambridge: Cambridge University Press, ...)
21. “U.S. Army Combat Psychiatry [pdf],” War Psychiatry, 154.
22. F. C. Hitchcock. Stand To: A Diary of the Trenches, 1915–1918. (London: Hurst & Blackett, 1937; repr., Heathfield, England: The Naval & Military Press, Ltd., 2001).
23. “Psychiatric Lessons of War [pdf], ” War Psychiatry, 9.
24. Ibid.
25. Ibid, 11.
26. Paul Wanke, “American Military Psychiatry and Its Role Among Ground Forces, ” The Journal of Military History 63, no. 1 (January 1999): 127.
27. “Psychiatric Lessons of War [pdf], ” War Psychiatry, 11–12.
28. Ibid.
29. Peter J. Murphy, “The Stress of Deployment,” Military Stress and Performance: The Australian Defence Force Experience, (Melbourne: Melbourne University Press, 2003), 7.
30. “Psychiatric Lessons of War [pdf], ” War Psychiatry, 16-17.
31. Ibid.
32. Ibid.
33. Kate Mulligan, “For PTSD Care, It’s a Long Way from Vietnam to Iraq,” Psychiatric News 39, no.9 (May 7, 2004): 1
    
34. Gerald Nicosia, Home to War: A History of the Vietnam Veterans’ Movement (New York: Carroll & Graf Publishers, 2001), 158–159
35. Ibid., 179
36. Ann Scott Tyson, “Suicides in Marine Corps Rise by 29%,” Washington Post, February, 25, 2005.
    
37. “Army Suicides Hit Highest Level Since 1993,” Associated Press, April 21, 2006.
38. Bret A Moore and Greg M. Reger, “Combating Stress in Iraq,” Scientific American, February/March 2006, 35.