Edgar Jones

Post-combat syndromes from the Boer war to the Gulf war: a cluster analysis of their nature and attribution

Abstract Objectives: To discover whether post-combat syndromes have existed after modern wars and what relation they bear to each other. Design: Review of medical and military records of servicemen and cluster analysis of symptoms. Data sources: Records for 1856 veterans randomly selected from war pension files awarded from 1872 and from the Medical Assessment Programme for Gulf war veterans. Main outcome measures: Characteristic patterns of symptom clusters and their relation to dependent variables including war, diagnosis, predisposing physical illness, and exposure to combat; and servicemens changing attributions for post-combat disorders. Results: Three varieties of post-combat disorder were identified — a debility syndrome (associated with the 19th and early 20th centuries), somatic syndrome (related primarily to the first world war), and a neuropsychiatric syndrome (associated with the second world war and the Gulf conflict). The era in which the war occurred was overwhelmingly the best predictor of cluster membership. Conclusions: All modern wars have been associated with a syndrome characterised by unexplained medical symptoms. The form that these assume, the terms used to describe them, and the explanations offered by servicemen and doctors seem to be influenced by advances in medical science, changes in the nature of warfare, and underlying cultural forces.

Forward psychiatry in the military: its origins and effectiveness.

Abstract“Forward psychiatry” was devised in World War I for the treatment of shell shock and today is the standard intervention for combat stress reaction. It relied on three principles: proximity to battle, immediacy, and expectation of recovery, subsequently given the acronym “PIE.” Both US and UK forces belatedly reintroduced PIE methods during World War II to return servicemen to active duty and made confident claims for its efficacy. Advanced treatment units also appeared to have minimized psychiatric battle casualties during Korean and Vietnamese Wars. Evaluations of its use by Israeli forces in the Lebanon conflict showed higher return-to-duty rates than at base hospitals. A reexamination of these examples suggests that reported outcomes tended to exaggerate its effectiveness both as a treatment for acute stress reaction and as a prophylaxis for chronic disorders such as PTSD. It remains uncertain who is being served by the intervention: whether it is the individual soldier or the needs of the military.

Unexplained symptoms after terrorism and war: an expert consensus statement

Learning ObjectivesDescribe the characteristics of unexplained post-exposure symptoms that favor a causal association with a catastrophic event such as war or a terrorist act.Suggest possible ways in which pre-event interventions might prevent or minimize post-exposure symptoms.What measures might be taken during or after a catastrophic event to lessen or eliminate post-event symptoms? Twelve years of concern regarding a possible “Gulf War syndrome” has now given way to societal concerns of a “World Trade Center syndrome” and efforts to prevent unexplained symptoms following the most recent war in Iraq. These events serve to remind us that unexplained symptoms frequently occur after war and are likely after terrorist attacks. An important social priority is to recognize, define, prevent, and care for individuals with unexplained symptoms after war and related events (eg, terrorism, natural or industrial disasters). An international, multidisciplinary, and multiinstitutional consensus project was completed to summarize current knowledge on unexplained symptoms after terrorism and war.

Alcohol use and misuse within the military: A review

Abstract Traditionally alcohol has been used by the military to cope with the intense stress of battle but also as a way of mediating the transition from the heightened experience of combat to routine safety. The use of alcohol has divided medical opinion. Some doctors viewed it as wholly harmful to both social and occupational function and to health, while others argued that alcohol had a specific role in lifting morale, aiding unit cohesion and protecting soldiers from adjustment disorders. Although alcoholism has always been identified as incompatible with military service, the effects of habitual heavy drinking among military personnel are less well understood. Recent studies have suggested that young single males and those who have undergone particularly stressful experiences are at greatest risk of misusing alcohol. These associations, observed in the aftermath of recent conflicts in Iraq and Afghanistan, have again raised questions about the place of alcohol in military culture.

Screening for vulnerability to psychological disorders in the military: an historical survey

Objectives: To evaluate attempts in the military to screen for vulnerability to psychological disorders from World War I to the present. Methods: An extensive literature review was conducted by hand-searching leading medical and psychological journals relating to World Wars I and II. Recent publications were surveyed electronically and UK archives investigated for British applications. Results: Despite the optimism shown in World War I and the concerted efforts of World War II, followup studies showed that screening programmes did not succeed in reducing the incidence of psychological casualties. Furthermore, they had a counter-productive effect on manpower, often rejecting men who would have made good soldiers. Continued experimentation with screening methods for psychiatric vulnerability failed to yield convincing results during the post-war period. Conclusions: Although well-measured variables, such as intelligence, have been shown to predict success in training and aptitude, no instrument has yet been identified which can accurately assess psychological vulnerability. Previous attempts have failed because of false-positives, false-negatives and reluctance in the target population because of stigma. Early findings suggest that psychological surveillance, if not screening, may yield valuable results when applied to military populations exposed to stress.

Historical approaches to post-combat disorders

Almost every major war in the last century involving western nations has seen combatants diagnosed with a form of post-combat disorder. Some took a psychological form (exhaustion, combat fatigue, combat stress reaction and post-traumatic stress disorder), while others were characterized by medically unexplained symptoms (soldiers heart, effort syndrome, shell shock, non-ulcer dyspepsia, effects of Agent Orange and Gulf War Syndrome). Although many of these disorders have common symptoms, the explanations attached to them showed considerable diversity often reflected in the labels themselves. These causal hypotheses ranged from the effects of climate, compressive forces released by shell explosions, side effects of vaccinations, changes in diet, toxic effects of organophosphates, oil-well fires or depleted-uranium munitions. Military history suggests that these disorders, which coexisted in the civilian population, reflected popular health fears and emerged in the gaps left by the advance of medical science. While the current Iraq conflict has yet to produce a syndrome typified by medically unexplained symptoms, it is unlikely that we have seen the last of post-combat disorders as past experience suggests that they have the capacity to catch both military planners and doctors by surprise.

Public Panic and Morale: Second World War Civilian Responses Re-examined in the Light of the Current Anti-terrorist Campaign

Following September 11 in the US and July 7 in the UK, the threat to civilians from terrorist attack has become real yet considerable disagreement exists about how people might respond. The effect of aerial bombing on the publics morale during the Second World War and the incidence of psychiatric casualties have been explored to provide reference points for the current terrorist threat. Systematic study of restricted government investigations and intelligence reports into the effect of air‐raids on major British towns and contemporary medical publications have shown that panic was a rare phenomenon and arose in defined circumstances. Morale fluctuated according to the intensity of attacks, preparedness and popular perceptions of how successfully the war was being conducted. Resilience was in part a function of the active involvement of the public in its own defence but also reflected the inability of German bombers to deliver a concentrated attack over a wide area. Most civilians, by their very numbers, were likely to survive. Inappropriate or excessive precautionary measures may serve to weaken societys natural bonds and, in turn, create anxious and avoidant behaviour. Weapons that tap into contemporary health fears have the greatest psychological impact. Efforts by government to engage the public not only build trust but may also make an effective contribution to the campaign against terrorism.

Is violent radicalisation associated with poverty, migration, poor self-reported health and common mental disorders?

Background Doctors, lawyers and criminal justice agencies need methods to assess vulnerability to violent radicalization. In synergy, public health interventions aim to prevent the emergence of risk behaviours as well as prevent and treat new illness events. This paper describes a new method of assessing vulnerability to violent radicalization, and then investigates the role of previously reported causes, including poor self-reported health, anxiety and depression, adverse life events, poverty, and migration and socio-political factors. The aim is to identify foci for preventive intervention. Methods A cross-sectional survey of a representative population sample of men and women aged 18–45, of Muslim heritage and recruited by quota sampling by age, gender, working status, in two English cities. The main outcomes include self-reported health, symptoms of anxiety and depression (common mental disorders), and vulnerability to violent radicalization assessed by sympathies for violent protest and terrorist acts. Results 2.4% of people showed some sympathy for violent protest and terrorist acts. Sympathy was more likely to be articulated by the under 20s, those in full time education rather than employment, those born in the UK, those speaking English at home, and high earners (>£75,000 a year). People with poor self-reported health were less likely to show sympathies for violent protest and terrorism. Anxiety and depressive symptoms, adverse life events and socio-political attitudes showed no associations. Conclusions Sympathies for violent protest and terrorism were uncommon among men and women, aged 18–45, of Muslim heritage living in two English cities. Youth, wealth, and being in education rather than employment were risk factors.

Might depression, psychosocial adversity, and limited social assets explain vulnerability to and resistance against violent radicalisation?

Background This study tests whether depression, psychosocial adversity, and limited social assets offer protection or suggest vulnerability to the process of radicalisation. Methods A population sample of 608 men and women of Pakistani or Bangladeshi origin, of Muslim heritage, and aged 18–45 were recruited by quota sampling. Radicalisation was measured by 16 questions asking about sympathies for violent protest and terrorism. Cluster analysis of the 16 items generated three groups: most sympathetic (or most vulnerable), most condemning (most resistant), and a large intermediary group that acted as a reference group. Associations were calculated with depression (PHQ9), anxiety (GAD7), poor health, and psychosocial adversity (adverse life events, perceived discrimination, unemployment). We also investigated protective factors such as the number social contacts, social capital (trust, satisfaction, feeling safe), political engagement and religiosity. Results Those showing the most sympathy for violent protest and terrorism were more likely to report depression (PHQ9 score of 5 or more; RR = 5.43, 1.35 to 21.84) and to report religion to be important (less often said religion was fairly rather than very important; RR = 0.08, 0.01 to 0.48). Resistance to radicalisation measured by condemnation of violent protest and terrorism was associated with larger number of social contacts (per contact: RR = 1.52, 1.26 to 1.83), less social capital (RR = 0.63, 0.50 to 0.80), unavailability for work due to housekeeping or disability (RR = 8.81, 1.06 to 37.46), and not being born in the UK (RR = 0.22, 0.08 to 0.65). Conclusions Vulnerability to radicalisation is characterised by depression but resistance to radicalisation shows a different profile of health and psychosocial variables. The paradoxical role of social capital warrants further investigation.

War syndromes: The impact of culture on medically unexplained symptoms

The general principle that the experience of combat damages servicemens long-term physical and mental health is recognized.1 However, controversy has raged over the nature of particular post-combat disorders such as shell shock, disordered action of the heart (DAH), effort syndrome, effects of Agent Orange and, not least, Gulf War syndrome.2 We, among many others, have argued that they should be classified as functional syndromes3 characterized by medically unexplained symptoms,4 which include: fatigue, weakness, sleep difficulties, headache, muscle ache and joint pain, problems with memory, attention and concentration, nausea and other gastro-intestinal symptoms, anxiety, depression, irritability, palpitations, shortness of breath, dizziness, sore throat and dry mouth.5 Despite popular claims to the contrary, no simple biomedical aetiology has been discovered to account for these disorders, hence the term “medically unexplained”.6 Furthermore, they are not easily interpreted using accepted psychiatric classifications. Without demonstrable organic cause, war syndromes have attracted diverse causal explanations, ranging from pressure on the arteries of the chest, constitutional inferiority, toxic exposure, bacterial infection to microscopic cerebral haemorrhage. One area of understandable confusion is the relationship between conventional psychiatric disorders, in particular post-traumatic stress disorder (PTSD), and syndromes characterized by medically unexplained symptoms. This lack of clarity is hardly surprising since both can arise in the context of warfare. PTSD, first recognized as a legitimate psychiatric diagnosis in 1980,7 is defined in psychological terms as a disorder of traumatic memory, featuring nightmares, intrusive recollections and flashbacks (which overlap with the normal ways in which veterans remember their experiences), but also behaviourally since these features lead to avoidance and impaired social interaction. Hence, PTSD is distinct from functional somatic syndromes, such as irritable heart or DAH, which are defined by the presence of multiple, clinically-significant somatic symptoms but do not require overt psychological experiences such as nightmares or avoidant behaviour. However, these somatic disorders are associated, but are not synonymous, with anxiety and depression.8 Culture is an elusive phenomenon but has been defined as “systems of meaning” that “are necessarily the collective property of a group”.9 In essence, it refers to learned patterns of thought and behaviour characteristic of a given population. Culture, perhaps, has its greatest opportunity to influence the form of, and meaning attached to, medical disorders when scientific experiment and clinical investigation have failed to define or identify their aetiology. Functional somatic syndromes, which arise in the context of traumatic experience thereby evoking powerful feelings, may be particularly prone to the impact of such forces. Edward Shorter argued that individuals possess a “symptom repertoire”, which is available to both the conscious and unconscious mind for the physical expression of psychological conflict.10 Particular symptoms may appear in specific periods partly as a result of underlying cultural trends. At a societal level, popular health fears alert patients to particular areas of the body and can offer explanations that resonate with widely shared beliefs. Servicemen during the Second World War, for example, may have tended to emphasize gastro-intestinal symptoms because of the general fear of peptic ulcer. Not only would dyspepsia and stomach pain convey a sense of seriousness, they would plausibly gain the attention of a regimental medical officer primed to invalid men who might break down in action. At a professional level, doctors are likely to look for, or to emphasize, symptoms that fall within their specialist area or are considered significant at the time. A gastroenterologist will tend to look for stomach-related symptoms and pay less attention to muscular and joint pains than, say, a rheumatologist.11 Given the rising incidence of peptic ulcer during the 1940s and the risk of death from perforation, physicians paid particular attention to dyspepsia in individuals who might serve in situations without ready access to emergency medical services. The very real difficulties of making an accurate diagnosis, often led to multiple and varied investigations. In the mind of the serviceman, this attention may have reinforced any belief that his gut pain had a life-threatening cause. Thus, the selection of symptoms, the weight that is attached to them and the explanations that follow from both doctors and patients were likely to have been subject to cultural forces. Furthermore, it is hypothesized that the form taken by war syndromes was influenced by the evolving nature of combat: not least the effect of new technology on weaponry but also the impact of “modernity” in Weberian terms of the growth and differentiation of bureaucracy; the application of standardization and routine to administrative action; and the employment of experts to define and order such systems.12 The role of the soldier and his place in society plausibly influenced the behaviour of veterans and the explanations offered for such post-combat disorders as they experienced. Although considerable research has been directed towards the cultural history of PTSD,13 war syndromes have been somewhat neglected. Some studies have assumed that PTSD is, in effect, a modern re-interpretation of popular diagnoses of earlier wars. Dean argued, for example, that the symptoms of PTSD, including flashbacks, can be identified in the accounts of veterans of the American Civil War.14 Indeed, some have argued that railway spine and shell shock were simply PTSD by other names.15 Furthermore, there is a “Whiggish” tendency, notable in the quasi-historical accounts of some contemporary trauma specialists, to assume that PTSD trumps all previous conditions as we move in a steady progression from ignorance to post DSM-III enlightenment. In this paper we seek to assess the impact of culture on the expression and interpretation of functional somatic syndromes during the Boer War, First and Second World Wars and the Gulf conflict. Medically-unexplained symptoms are explored in their own right and not simply as the putative ancestors of PTSD. We will then compare evidence derived from random samples of servicemen suffering from war syndromes with contemporary accounts in an attempt to understand the form of these disorders.