Attrition: Searching For The Line That Must Not Be Crossed


April 14, 2010: The U.S. Army has found that PTSD (post-traumatic stress disorder) often does not appear immediately after combat, but gradually, over a longer (5-10 year) period. Short term, the army has found that 14 percent of troops on their first combat tour have stress problems. That goes to 18 percent for those on their second tour, and 31 percent for those on their third. But in the longer term (after five years of being in combat), 24 percent of troops who have served 12 months (one tour) in a combat zone will develop some PTSD. That goes to 39 percent for those who serve two tours and 64 percent for those who do three. The army wants to limit the number of troops suffering from PTSD. This is essential if the army is to maintain an experienced combat force.

A growing proportion of NCOs and officers are doing their third or fourth combat tours (in Iraq or Afghanistan), and that means more and more of them are approaching the point where they will have to take a non-combat job. Otherwise, they risk severe mental problems from the accumulated stress. In effect, PTSD (post-traumatic stress disorder) epidemic has been created by the unprecedented exposure of so many troops, to so much combat, in so short a time. Once a soldier has PTSD, they are usually no longer fit for combat, and many troops headed for Afghanistan are falling into this category. PTSD makes it difficult for people to function, or get along with others. With treatment (medication, and therapy), you can recover from PTSD. But this can take months or years. In extreme cases, there is no recovery. And while being treated, you stay away from the combat zone.

The army has found that PTSD can be delayed, or even avoided, by providing the troops with what previous generations of soldiers would have considered luxuries. For example, when possible, combat troops sleep in air conditioned rooms, and have access to the Internet and video games, as well as good food and other amenities. The video games and Internet resulted in an unexpected positive effect. The surveys found that troops that spent 2-4 hours a day on the Internet or playing video games (even violent ones) had far fewer stress problems. Having exercise facilities available also helped, despite the physically strenuous nature of combat in Afghanistan. While the combat troops spend most of their time out in the countryside, living rough, their commanders know that even a few days back at a larger base, with all the goodies, makes a big difference in attitudes, morale and combat effectiveness.

Nearly a century of energetic effort to diagnose and treat PTSD (including much recent attention to civilian victims, via accidents or criminal assault), had made it clear that most troops eventually got PTSD if they are in combat long enough. During World War II, it was found that, on average, 200 days of combat would bring on a case of PTSD for American troops. After World War II, methods were found to delay the onset of PTSD (more breaks from combat, better living conditions in the combat zone, prompt treatment when PTSD was detected). This has extended their useful time in combat, before PTSD sets in. In effect, troops can now endure much more than 200 days of combat before coming down with PTSD. But there is no way to make anyone immune to PTSD, even though some people have a natural immunity. This has sparked billions of dollars in research to find medical cures for PTSD, as well as medications that will delay, or prevent, the onset of PTSD.

The army is aggressively treating PTSD. Part of that is a program that mandates a mental health evaluation for everyone in the army. Those who have not been in combat will serve as a baseline for comparing to those who have. Moreover, the army wants to find out to what extent non-combat operations (training can often be quite intense) can add to the stress that could eventually lead to PTSD. The basic idea here is to "mainstream" PTSD, trying to convince all the troops that PTSD is just another occupational hazard, not something you should try and hide, and hide from. You can't, and increasingly, the army won't let you.

The army also detects, and treats, many PTSD sufferers by performing screening during the delivery of routine medical care, including annual checkups. Doctors are given a script that uses some simple and non-threatening questions to discover if the soldier might have PTSD. If further questioning reveals there may be some PTSD, the soldier is offered treatment as part of regular medical care, not a special PTSD program. It was those programs that put off many troops.

While most troops now accept that PTSD is not a sign of mental weakness, but a very real combat hazard, many still avoid special PTSD treatment programs. By making PTSD treatment (which is usually just monitoring, and the use of some anti-stress medication for a while), part of regular medical care, much of the stigma disappears.

The army find itself facing some new sources of PTSD. For example, there was the discovery that many troops, because of exposure to roadside bombs, and battlefield explosions in general, had developed minor concussions that, like sports injuries, could turn into long term medical problems. Often these concussions were accompanied by some PTSD.

Experience so far has shown that PTSD can be delayed, perhaps for a long time. When a soldier does come down with it, PTSD can often be treated, and its effects reversed. This has large ramifications for non-military medicine, for many civilians suffer from PTSD. That's because military recruits are screened for their ability to handle stress and resist PTSD. In the civilian community, there are far more people who can acquire PTSD after exposure to much less stress.





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