Combat-Related Stress Disorders

Post-Traumatic Stress Disorder (PTSD) is an anxiety disorder caused by traumatic or life-threatening events. Those whose lives are impacted by violence are at risk of developing this disorder, which includes (but is not exclusive to) those engaged in military combat.

PTSD affects military personnel around the world, and war zone veterans are at risk. In the Veterans Affairs Canada (VAC) year-to-date statistics (as of June 2017), show that more than 18,000 of Canada’s CAF and RCMP veterans with a PTSD diagnosis were receiving disability benefits.

Types and Severity
There are five different types of PTSD, the severity of which can be categorized as Acute (symptoms last up to three months after trauma); Chronic (symptoms last three or more months); or Delayed (at least six months have passed between the traumatic event and the onset of symptoms).

  1. Uncomplicated PTSD

Uncomplicated PTSD is caused by continued exposure to traumatic events. As a result, individuals affected often attempt to avoid all stimuli associated with the trauma, sometimes through denial of symptoms. This can lead to numbing of emotions and the individual detaching from people and situations that might remind them of the traumatic event. Military personnel are usually diagnosed with this type of PTSD while in active service.

  1. Normal Stress Response

This occurs when healthy people experience difficulties such as isolation, feelings of unreality, body tension, distress, emotional numbing, and bad memories – usually from exposure to a single traumatic event. Many veterans have been diagnosed with this form of PTSD and have successfully recovered, although there is the need to be alert to potential relapse when faced with heavier than normal everyday stresses.

  1. Complex PTSD

As with Uncomplicated PTSD, individuals with Complex PTSD have been continuously exposed to traumatic situations. In the case of Complex PTSD, however, the prolonged trauma usually occurred in childhood, such as sexual, physical, or emotional abuse. Affected individuals tend to dissociate from the events, believing that the trauma will go away if they ignore it. This can result in personality or dissociative disorders developing later in life. The individual may also experience difficulties with depression, amnesia, rage, panic attacks, eating disorders, substance abuse, and promiscuity. While this diagnosis is less related to military experiences, veterans who have experienced trauma in their childhood are at risk of more severe PTSD as a result of their military duties.

  1. Acute Stress Disorder

This is a severe reaction to trauma and impacts a relatively small number of trauma survivors. Symptoms can include severe insomnia, paranoia, mental confusion, dissociation from activities such as work and relationships, panic attacks, and inability to manage personal care. This acute stress reaction is more likely to occur in individuals who have survived a major disaster, such as exposure to death or loss of home and community. Immediate support should be provided to survivors by first removing them from the scene of the trauma, and providing medication for relief of symptoms from anxiety, insomnia and grief. Immediate removal from the trauma is rarely feasible in a military situation and thus regular on-site counselling can help mitigate the effects of the disorder. Those exposed to terrorist attacks or who are under constant bombardment in enemy territory are particularly susceptible to this form of PTSD.

  1. Comorbid PTSD

Comorbid PTSD is diagnosed when symptoms are associated with other mental disorders such as anxiety, alcohol or substance abuse, depression, or panic disorder. To effectively manage this form of PTSD, the disorders must be treated at the same time rather than individually. Veterans who use alcohol or drugs to cope with their military experiences are at greatest risk of this form of PTSD.

Available Treatments
The Canadian Forces Members Assistance Program (CFMAP) is a 24-hour counselling service available as a first step towards dealing with mental health problems. However, when these problems reach the severity of PTSD, a referral to mental health professionals is necessary.

Master Corporal Isabelle Gagnon from the Sentinels program speaks with a member seeking advice. 
(DND Photo: Sgt Marc-André Clément, Army PA)

Treatment for PTSD, as outlined by VAC, is broken down into several steps. First, the patient is stabilized and information about PTSD is provided. Medication, such as antidepressants and anti-anxiety drugs, may be prescribed to manage the immediate symptoms of the disorder, while long-term therapy is provided to deal with the underlying trauma. Veterans often have access to these services through local clinic providers or military rehabilitation centers set up by the VAC and the Ministry for National Defence.

Cognitive Behavioural Therapies
Psychological treatment often incorporates Cognitive Behavioural Therapy. CBT is the most widely accepted psychotherapy and is considered the most effective for PTSD symptoms. CBT focuses on solving reactions to trauma by altering unhealthy thought patterns and behaviours. Originally designed to treat depression, its use has expanded to treating other mental health conditions, including PTSD.

Another form of CBT that is gradually gaining some acceptance as an effective treatment is Eye-Movement Desensitization and Reprocessing. In EMDR, the patient makes back and forth eye movements or follows constant sounds while recounting a traumatic event. Theoretically, focusing on other stimuli while recalling the traumatic event helps clients reprocess the event until it no longer has any negative psychological effects. However, studies are split on the necessity of the back and forth movement in EMDR, with some studies finding it is necessary and others reporting otherwise.

It should be noted, however, that CBT isn’t for everyone and has been criticized for its inability to address wider problems surrounding the PTSD, such as the role of childhood experiences and current personal relationships.

Psychodynamic psychotherapy is an alternative where therapists will dig deeper into both past and present experiences to get to the core of the PTSD and how an individual can best overcome it. Other alternatives include homeopathy and hypnosis. However, VAC warns that these methods are not as effective and should be done in association with a PTSD specialist.

Cognitive processing therapy (CPT) and prolonged exposure (PE) therapy are two of the most applied forms of CBT, with experts around the world recommending them as the initial treatment for PTSD. Both take about 10-12 weekly sessions to complete.

The focus of CPT is on the impact of the trauma, where clients are supported to identify negative thoughts related to the trauma and to understand how those thoughts may cause stress. Clients are then encouraged to replace those thoughts and learn how to cope with negative emotions.

Prolonged Exposure therapy involves repeatedly revisiting the trauma in a safe clinical setting, to help clients change their reaction to memories of the traumatic event, while at the same time learning how to manage and then conquer situations that induce fear and stress.

Challenges to Seeking Treatment
The first step of any treatment is the admission that help is needed. In the military, mental health is often not widely addressed, although acceptance and understanding is certainly improving. Still, many military personnel would rather suffer in silence as they were taught to be hardened and to carry on.

Due to the stigma of mental health as a sign of weakness, many active personnel as well as veterans are reluctant to step forward and seek the treatment they deserve.

It is important that, when someone does take that leap to seek diagnosis or treatment for possible PTSD, they need to be attended to immediately. Complaints have been made that local health providers only treat emergency cases as urgent, leaving veterans on a long waiting list, potentially for months, if their condition is not considered critical or urgent.

A Brighter Future
It is necessary to increase awareness about mental issues in the military, especially by reducing the stigma associated with seeking treatment during active service. Research comprising veterans of the Canadian Armed Forces has shown that spouses have a major role to play in the mental well-being of their military partners, both in a preventative role and in helping them cope with PTSD. With this in mind, it is imperative that military spouses undergo counselling either alongside their partners, or separately. Family counselling sessions can also be arranged, as family dynamics play an important role in the post-service aspects of veterans’ lives, including how they cope with PTSD.

In February 2018, a Bill was passed by Parliament to address PTSD. The Bill, entitled Federal Framework on Post-Traumatic Stress Disorder Act (C-211), called for health, military, and frontline government agencies, and members of medical community, including patients’ groups, to hold a summit to develop “…a comprehensive federal framework to address the challenges of recognizing the symptoms and providing timely diagnosis and treatment of post-traumatic stress disorder.”

Bill C-211 was developed in response to the high prevalence of PTSD among combat veterans and to the projected increases in the number diagnoses in future. It will now go on to a second reading with the hope that its implementation will be another positive step by the Canadian government towards taking an active role in understanding and providing better care for veterans dealing with stress disorders.

Dr Nicola Davies is a Psychologist and writer with an interest in the psychology behind frontline work. She regularly contributes articles to FrontLine Safety & Security magazine.