Meeting Military Mental Health Needs

Meeting Military
Mental Health
Needs in the 21st
Century and
Beyond: A
Critical Analysis
of the Effects of
Dualism, Disparity
and Scientific
Bias

Mark Russell, Ph.D.,
CDR, MSC, USN

2008 EMDRIA
Conference, Phoenix,
Arizona (9/14/08)

Standard Disclaimer

The opinions and views expressed here
are those of the presenter and should
not be considered the policy, opinion,
or position of the United States Navy or
Department of Defense (DoD)

Medical Dualism and Mental Health
Disparity within Military Medicine
―I‘m not a fan of
the facts. Facts
change, but my
opinion will
never change,
no matter what
the facts are.‖

How Far Have We Progressed?
Before 20th century- ‘culture of trauma‘-―The
idea that a soldier of previously sound mind
could be so emotionally disturbed by
combat that he could no longer function was
not entertained; that he might suffer long-
term psychological consequences of battle
was also dismissed‖ (Jones and Wessely, 2007; p. 165)

―It is important to remember that
most psychiatric casualties are
soldiers who… unconsciously seek
a medical exit from combat‖

Current U.S. Army ‗Textbook of Military
Medicine: War Psychiatry‘ (Jones, 1995)

‗Lessons Learned and Unlearned‘ or
Lessons Never Learned?
• WWII U.S. Army psychiatrists Appel and Beebe (1946)
concluded, ―Every man had a breaking point and
neuropsychiatric casualties should be viewed as
inevitable as gunshot and shrapnel wound in warfare.‖

• In reality-military historian Edgar Jones (2006), ―past
experience suggests that [post-combat disorders] have
the capacity to catch both military planners and
doctors by surprise‖ (p. 533).

Mind-Body Dichotomy: Dualism
• 18th Century-‗Cartesian
Dualism,‘ emerges as
dominant European
philosophy
• Mind and body seen as
fundamentally unique and
separate
• Physical health and illness
viewed as the only authentic
focus of medical science

Mental Health Disparity
• Gross inequality between physical and
mental healthcare
• Unequal value, prioritization, status
and resources afforded to mental
healthcare science, practice, patients
and providers

The Take Away:
Five Critical Unlearned Lessons
1. That the actual prevalence of post war disorders is
historically grossly under-estimated by not
accounting for the full-spectrum of psychophysical
reactions, rampant stigma and barriers to care.
2. That every human being is vulnerable to acute and
chronic breakdown due primarily to cumulative
effects of war and/or traumatic stress regardless of
predisposition or resiliency factors.
3. That the psychophysical wounds of war are
fundamentally similar, authentic and morally
indistinguishable from war‘s tangible injuries.

The Take Away:
Five Critical Unlearned Lessons (cont.)
4. That the current antiquated dualistic healthcare
paradigm, policy and practices results in harmful
mental health neglect, stigma and disparity
perpetuating cyclical crises and unjust trauma-
pension wars.

5. That 21st century medicine must adopt an
integrated (holistic) healthcare paradigm, policies
and practices with full mental health parity in order
to prevent future broken promises and failure to
meet the mental health needs of war veterans and
their families.

Reasons for Cyclical Failures in Meeting
Wartime Mental Health Needs

Natural Disasters Humanitarian Relief

• 2008 Myanmar -
earthquake
• 2005 Indonesian -
Tsunami
• 2005 Hurricane Katrina

Training Exercises & Peace-Keeping
• •

Sexual Assaults
• 2008 DoD Sexual
Harassment &
Assault Report for
FY07
• 2,688 cases
• 60% alleged rape
• 72% active-duty
rape victims

International Terrorism
•1982-Beirut, Marine Barracks
•1996-Saudi Arabia, Khobar Towers
•2000-Yemen, USS Cole
•2001-Washington DC, Pentagon

Combat Operations
• 40 wars or conflicts any given
year
• 1% world population are
refugees
• GWOT: 1.6 million U.S.
service personnel deployed
• KIA: 4,683 WIA: 32,799
Suicide: 179
• 303,000 PTSD/depression
(20%)

Prisoners of War (POW)
• Lifetime prevalence of
PTSD = 70% (current
rates 20-40%)
• Lost 35% body weight
poorest recovery

It‘s Not All Negative: Positive
Combat/Operational Stress

Positive Combat Stress Behaviors
• Unit cohesion: Loyalty to shipmates and
leaders. Identification with unit traditions.
• Sense of eliteness
• Sense of mission
• Alertness/Vigilance
• Exceptional strength and endurance
• Increased tolerance to hardship and pain
• Sense of purpose
• Increased faith
• Heroic acts: Courage and self-sacrifice

Carpe Diem?
• The DoD, by far, is in best position to be a
leader in the World on scientific advancement
in:
• Understanding
• Assessment
• Prevention (resilience) and
• Treatment of traumatic stress
• We have yet to seize the opportunity!---WHY?

THE PROMISE
• ―Making appropriate and timely
counseling available to our men
and women is essential to
mitigating longer term effects.‖

• ―The Military Health System is
committed to doing everything
possible to help our service
members remain healthy, including
providing access to high-quality
William Winkenwerder, M.D.,
Assistant Secretary of Defense for
mental health services.‖
Health Affairs (July, 2004)

Unprecedented Mental Health
Initiatives in DoD: A Story
That Deserves Telling

Post-Deployment Health Screenings

Plethora of Information Available to
Service Members And Their Families

Access to Alternative Counseling Resources

The Untold
Story of
Mental
Health Care
in DoD
Narrated by:
Mark Russell, Ph.D.,
CDR, MSC, USN

Multinational Medical
Conference, Yokosuka,
Japan (9/20/06)

―The Perfect Storm‖
• Storm One: High Mental Health Demand
• Storm Two: Lack Of Access To Quality
Mental Health Care
• Storm Three: Strong Undercurrent of
Dualism, Neglect and Mental Health
Disparity

High Mental Health Demand

The First Storm

Reported Mental Health Problems
Among Army & Marine Personnel
After Iraq Deployment*
Depression
Anxiety Based On 2003-2004 Data!
35% PTSD
Any of These
27.9% 29.2%
30%
25%
19.9%
20% 17.5%18.0%
15.2% 14.7%15.7%
15%
10%
5%
0%
Army Study Group Marine Study Group
Source: Hoge, et al, “Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers
to Care,” New England Journal of Medicine, v. 351, no.1, July 1, 2004, pp. 13-22.

OEF/OIF Spectrum of Medical
Diagnoses in VA (n = 144,424)
Musculoskeletal 40%
Mental disorders 32%
Digestive System 30%
Ill Defined Symptoms 30%
Nervous system 28%
Respiratory 17%
Injury/Poisoning 16%

VHA Office of Public Health and Environmental Hazards, February 14, 2006

Time Period Neuropsychiatric (NP) Conditions *Medically-Unexplained Symptoms (MUS)

Crimean War Melancholia; Insanity; Mania; Inebriation Epilepsy; Rheumatism; Irritable heart
(1854-1856)

U.S. Civil War Insanity; Melancholia; Mania; Nostalgia Rheumatism; Mental Aches; Dropsy;
(1861-1865) Monomania; Inebriation; Nervous Prostration; Functional constipation; Neuralgia;
Inflammation of Brain; Malingering Irritable Heart; Epilepsy; Sunstroke; Chronic Diarrhoeas

Boer War Insanity; Melancholia; Mania; Nervous Debility; Debility; Rheumatism; Disordered Action of the Heart
(1899-1902) Neurasthenia; Psychosis; Inebriation; Nervous Shock (DAH); Sunstroke

Russo-Japanese Insanity; Hysteria; Hypochondria Brain Disease; Epilepsy; Brain/Spinal Cord Disease;
War (1904-1905) Traumatic Neurosis; Nervous Exhaustion; War Neurosis Peripheral Nervous System/paralysis

WWI Insanity; Mental Defect; Psychosis; Manic-Depression; Disordered Action of the Heart (DAH)
(1914-1918) Psychoneurosis; Shell shock; Neurasthenia; Traumatic Effort Syndrome; Rheumatism; Epilepsy; Vascular Disease of
Neurosis; Alcoholism; Drug Addiciton; Constitutional the Heart (VDH); Cardiac Neurosis; Neurocirculatory
Psychopathy; Nervous Ilness; Nervous Disease; Asthenia; Endocrinopathies; Soldier’s Heart; Evacuation
Melancholia; War Hysteria; War Neurosis; Gas Hysteria; Syndrome; Concussion Syndrome; Enuresis’ Neuralgia;
Functional Nervous Disorder; Anxiety Neurosis; Paralysis without specified cuase; Defective speech;
Exhaustion Neurosis; Hypochondriasis; Psychasthenia;
Malingering

WWII Psychosis; Psychoneurosis; Alcoholism; Character- Non-ucler Dyspepsia; Epilepsy; Heart Disease; Contusion
(1939-1945) Behavior Disorder; Disorder of Intelligence; Lacking Injuries; Disordered Nervous System; Rheumatism; Cardiac
Moral Fiber; Battle Neurosis; Hysteria; Nervous Neurosis; Enuresis; MUS of gastrointestinal, cardiovascular
Exhaustion; War Neurosis; Reactive Neurosis; Old and musculoskeletal systems; peptic ulcer; hypertension;
Sergeant’s Syndrome; Mental Weakness; Fear Neurosis; allergic disorders; dermatological conditions; Migraine;
Immaturity Reaction; Wartime Neurosis; Malingering Neurological defects

Lack Of Access To Quality
Mental Health Care

The Second Storm

Rapid Attrition of DoD Mental Health
Providers: The Silent Crisis In Navy
Psychology
140
• 135 Total Billets
120
• 80 Filled (59%)
100 • 12 Training
80 Billets • 68 Deployable
Filled
60 • 10 on Carriers
Deploy
40 • 5 RAD/retirement
20
request per month

0
8/1/2006

Lack Of Adequate Training To
Respond To Mental Health Needs

Problems With Access to Quality
Mental Health Care (DVA/DoD, 2004)

• ―Psychotherapies should be provided by
practitioners who have been trained in the
particular method of treatment, whenever
possible [Expert Consensus] (pg 9
summary).‖

2003-2005 – DoD Mental Health Training
Needs Survey (Russell & Silver, 2006)
• 133 MH providers in DoD surveyed
• 90% reported they have received no training
or supervision per VA/DoD CPG on any of
the best treatments of PTSD
• No systemic training
(internship/residencies) on management or
treatment of traumatic stressors
• What if these were dentists or surgeons?

LACK OF MENTAL HEALTH
PARITY

The Third Storm

Inside The Third Storm

Entrenched Medical Dualism:
Mental Health Disparity, Stigma and
Neglect

The ‗Untold Story‘

Name One Medical Innovation by DoD
Medical Research and Practice?
• Importance of sanitation in field medicine – U.S. Civil War
• Infection control – Army Major Walter Reed proves cause of yellow
fever led to eradication – Spanish-American War
• Use of x-ray machine, plastic surgery, tetanus antitoxin – WWI
• Blood transfusions – WWI
• Blood plasma – WWII
• Helicopter medevac, MASH, - Korea
• Damage control surgery, use of gortex to keep wounds open
• Army designed tourniquet – used w/ one hand
• Bandage made compressed shells of shrimp – fuses to red blood
cells
• State of the art centers for burn, amputees, prosthetics, pain
• 93% survival rate in OIF/OEF!!!

Disparity: Increasing Survival Rate of
Physically Injured Soldiers

• WWII: 23% of injured combatants died

• Vietnam: 17% of injured combatants died

• Iraq/Afghanistan: 9% of injured
combatants die

Gawande A. Casualties of War—Military Care for the Wounded from Iraq and Afghanistan. NEJM
351(24): 2471-2475.

Name One Major Mental Health
Innovation by DoD?
• ……………………………………….???

• None!
• Despite frontline psychiatry since 1917

Combat Stress Injuries:

Challenges for the
21st Century
CAPT Bill Nash, MC, USN
Combat/Operational Stress Control
Coordinator
Headquarters, Marine Corps

When Did We Decide
That Combat Stress
and PTSD Are NOT
Primarily a “Sickness
of Will”?
Let Today Be That
Day
(CAPT W. Nash, 2/6/07)

Evidence of Dualism, Neglect and
Disparity of Mental Health Care in DoD?
• Inadequate training of healthcare providers on post
deployment MH issues
• Grossly insufficient staffing levels of MH providers
• Lack of MH treatment training and monitoring
• Significant disparity (chronic neglect) in research
• Lack of regional research treatment centers for
traumatic stress reactions until November 2007
• MHAT-IV recommendation, ―publish a policy that
ensures Soldiers/Marines are able to access mental
health during the duty day‖ (OSG, 2007; p. 33).

Further Evidence of Dualism and Disparity
• Non-medical MH providers (psychologist, social
workers, and chaplains) - provide majority of
psychotherapy
• Disparity in promotion of non-medical MH providers
• Glass ceiling for non-medical MH providers
• Inexplicable discrepancy in monetary compensation
between medical and non-medical MH providers
• Maximum specialty bonus is $2,000 annual (10 yrs of
less) or $5,000 (10 or more yrs)
• Medical specialty pays include Dermatology $18,000;
Pediatrics $12,000; Family Practice $13,000; and
Psychiatry $15,000.
• No MH retention incentives offered until 2008

Direct Effects of Dualism and Disparity:
Entrenched Stigma
Perceived as Weak 65%

Unit Leadership Might Treat Differently 63%

Unit Members Might Lose Confidence in Me 59%

Difficulty Getting Time Off for Treatment 55%

Leaders Would Blame Me for Problem 51%

Would Harm My Career 50%

Difficult to Schedule Appointment 45%

Too Embarrassing 41%

Don't Trust Mental Health Professionals 38%

Mental Health Care Doesn't Work 25% Stigma of mental
Don't Know Where to Get Help 22% health problems
Don't Have Adequate Transportation 18% remains
0% 10% 20% 30% 40% 50% 60% 70%
Source: Hoge, et al, “Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers
to Care,” New England Journal of Medicine, v. 351, no.1, July 1, 2004, pp. 13-22.

Military Organizational Structural
Support for Dualism and Disparity
SURGEON GENERAL

MEDICAL CORPS

DENTAL CORPS

CHAPLAIN CORPS

LEGAL CORPS

SUPPLY CORPS

MEDICAL SERVICE CORPS

ADMINISTRATIVE

CLINICAL

MENTAL HEALTH CORPS

Reporting Failures of 21st Century Military
Mental Health Care: What‘s the Difference?
• January 2004 (Russell) • June 2007 (DoD Task Force)
• Critical shortage of MH • Critical shortage of MH
clinicians clinicians
• High MH staff attrition • High MH staff attrition
• Poor MH training (i.e., 90% • Poor MH training (i.e., 90%
untrained on EBT-PTSD) untrained on EBT-PTSD)
• Restricted access to quality MH • Restricted access to quality MH
treatment treatment
• Insufficient clinical research • Insufficient clinical research
• Inadequate general training on • Inadequate general training on
MH issues MH issues
• Need for anti-stigma campaign • Need for anti-stigma campaign
• Establish state of art regional • Establish state of art regional
research and treatment center research and treatment center
• Eliminate root causes of
dualistic healthcare and mental
health disparity

Screaming Into The Storm
• After 2003 OEF/OIF deployment, extensive efforts made
to utilize military complaint resolution system to prevent
the current MH crisis including:
• 27 - Memoranda, point papers, data-driven reports sent
to over 50 military/civilian leaders:
– (2003-06) found 90% of 133 DoD MH staff not trained
to tx PTSD per VA/DoD CPG
• 15 -Approved media appearances; 6 -professional
publications; 16 - professional presentations; and 9 -
awards received
• 2- Formal IG complaints (Dec 05/Jan 06)
• 1 - Appearance w/ DoD MH Task Force (Oct 06)

21st Century Military Medicine:
Dualistic & Disparity or Holistic & Parity?
• DUALISTIC VIEWS • HOLISTIC VIEWS
• Mental health & illness as • Mental health & illness as
fundamentally unique and inseparable and
separate from physical interdependent from physical
• Emphasizes predispositions • Emphasizes toxic war stress
and weakness as causal as primarily causal
• Questions authenticity • Authenticity equal to physical
• Perpetuates stigma • Reduces stigma
• Under-values mental health • Parity in priority, value and
science and treatment resources toward mental
• Justifies disparity in priority, health science and treatment
resources and compensation • Ensures cost effective
• Ensures cost ineffective integrated healthcare
fragmented healthcare

Why Are Critical Lessons Unlearned?
Fleet Hospital Eight (2003)
―Very impressive work,
however…unfortunately, it
will all be forgotten at the
end of the war until
someone else rediscovers
it!‖ RADM Diaz, MC, USN

EMDR Treatment for OIF-related
ASD/PTSD (Russell, 2006)
E M D R T reatm ent F or C om bat R el
ated
S tress

50
45
40
35
30
25
20
15
10
5
0
Pr I
e ES P ost IES
P at ent
i 1 31 5
P at ent
i 2 38 15
P at ent
i 3 42 8
P at ent
i 4 44 10

U.S. Medicine (2004)
‗PTSD Prevention, Care Techniques Debated‘
• quot;PTSD is often a treatment resistant
problem. It is better to prevent it
altogether than to treat it, said Cdr.
Jack Pierce, MC, USN, clinical
program staff officer for Marine
Corps Medical Matters. ―
• ―The report also said there is no
evidence that eye movement
desensitization and reprocessing
(EMDR) as an early mental health
intervention following disasters so
should not be considered a
treatment of choice.‖ (COL Ritchie)
• quot;The new elements related to eye
movements are not central to the
effectiveness of the treatment.quot; (R.
Ursano, USUHS)‖

Psychological Consequences of War and
Violent Conflict

What is War?
• Carl von Clausewitz ‗On
War‘ (1790)
• ―War is the act of force to
compel our enemy to do
our will….a continuation
of political intercourse.‖

War Stress Injuries
• Why high prevalence of post
war disorder in 20th century?
• (1) Prevention of escape
behavior (desertions)
• (2) Greater exposure to
unpredictable, inescapable,
uncontrollable threats 24/7
• (3) Greater lethality of
weapons to inflict physical
and psychological injury
• (4) Psychological
conditioning to overcome
universal resistance to killing

The ‗Universal Human Phobia‘:
Psychological Resistance to Killing

A Brief History of
Warfare Evolution

The Trend in Lethality
10M
Fighter-bombers

WW2 tank
1000K
155mm Long Tom 500K
French 75mm
100K

10K
5000
18th Century 12-pounder
1000
500
Minie Rifle
100
Flintlock 50

20
Hand-to-Hand Weapons

400 BC 300 BC 200 BC 100 BC 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000

Quantifying Theoretical Lethality
• If one assumes that lethality is the inherent capability of a
given weapon to kill personnel or make material ineffective
in one hour, where capability includes range, rate of fire,
accuracy, radius of effects, and battlefield mobility, then
quantitative measures can be computed to compare
dissimilar weapons

Weapon Killing Capacity Weapon Killing Capacity

Sword 20 Minie rifle, muzzle-loading 154
Javelin 18 Late 19th Century breech-loading rifle
Simple bow 20 229
Longbow 34 Sprinfield Model 1903 rifle (magazine) 778
Crossbow 32 WW1 machine gun 12,730
Arquebus 10 French 75mm gun 340,000
16th C. 12-pounder cannon 43 WW1 fighter-bomber 229,200
17th C. matchlock musket 19 WW2 machine gun 17,980
17th Century 12-pounder cannon 229 US 155mm M2 quot;Long Tomquot; gun 533,000
18th Century flintlock musket 47 WW2 medium tank 2,203,000
18th Century 12-pounder cannon 3,970 WW2 fighter-bomber 3,037,900

Two Types of Tactical Swarming
“Massed Swarm” “Dispersed Swarm”
(Eurasian horse archers) (Somali Militia)

Example of Dispersed Swarming –
Mogadishu, 1993
Command and Control:
• Burning tires
• Runners
• Cell phones
• Megaphones
• Smoke from crash sites
• Sound of firefights

Elusiveness based on:
• Urban terrain
• Noncombatants
• Home turf
• Roadblocks, narrow alleys
equalized mobility

Combat Exposure for OIF Soldiers
Hoge et al. (2004)
Event Army (%) USMC (%)

Attacked/Ambushed 89 95
Being shot at/receiving fire 93/86 97/92
Shooting at enemy 77 87
Killing enemy combatant(s) 48 65
Handling human remains 50 57
Seeing injured 69 83
women/children
Seeing dead/injured 65 75
Americans
Killing non-combatant(s) 14 28
Being wounded 14 9

Intensity of Combat Exposure and
Post War Disorder Prevalence

A Few of the Many Stressors of
Operational Deployment
• Heat • Dehydration • Illness
PHYSICAL
• Cold • Sleep deprivation • Injury
• Alternating between hyper-focused & bored
MENTAL • Insufficient information• Value conflicts

EMOTION • Fear (of failure) • Hatred of the enemy
AL • Loss of friends • Guilt and shame

• Being away from loved ones and friends
SOCIAL
• Loss of personal space • Isolation
• Life doesn‟t make sense like it used to
SPIRITUAL
• Loss of faith • Loss of purpose

War-Zone Anticipation Stressors

Human Stress Response

Clinical Management

Mark Russell, Ph.D.

Physiological Response to Stress

Chronic stress & Acute stress

Pituitary Gland, Hypothalamus and Amygdala

Adrenal glands= Secrete hormones
Epinephrine Cortisol Glucocorticoids

Heart = beats faster
Arteries = widen
Stomach = digestion stops
Lungs = faster / shallow
Muscles = tense

Normal Combat Reaction (Menninger, 1948)
• 50% - pounding heart
• 45% - sinking stomach
• 30% - cold sweats
• 25% - nausea
• 25% - shaking/tremors
• 25% -muscle stiffness
• 20% - vomiting
• 20% - general weakness
• 10% - involuntary bowel
• 6% - involuntary urination

General Adaptation Syndrome (GAS)
• Stage 1: Alarm Phase
―fight, flight or freeze‖
response

• Stage 2: Adaptation or
Resistance phase

• Stage 3: Exhaustion or
breakdown phase

Cumulative Effects of Stress and Health

Variable impact of stress on immune
system
(Adapted from Robert Sapolsky in Merson, 2001)

Adaptive Coping vs. Stress Injury

Stress injuries
can heal

Bent by stress Injured by stress
– May feel irritable or anxious – May feel like you’ve “lost it”
– A gradual change – Often more abrupt change
– You still feel like yourself – Don’t feel like yourself any more
– You remain in control – You lose control

Brief History of War Stress Injuries

The ‗Zeitgeist‘
• German expression
meaning quot;the spirit of
the agequot;, literally
translated as quot;time
(Zeit) spirit (Geist)quot;
• prevailing intellectual
and cultural climate of
an era (Wikipedia,
2008)

Connecting Treatment to Etiology
• Beliefs about the causes of an ailment greatly influence
how we attempt to treat it.
• Consider how you would treat a ‗mental‘ impairment we
believe is caused by:
– Inherent weakness of character and/or constitution
– Lack of will power or moral fiber
– Suggestibility (i.e., from indulgent, self-oriented psychiatric
‗culture of trauma‘)
– Simulation or secondary gain (i.e., escape duty, pensions)
– Inadequate training and resiliency skills
– Legitimate psychophysical injury from physical environment
(i.e., cumulative effects of war or combat stress)

Managing Post War Disorders:
Effects of Mind-Body and Etiological Views
• DUALISTIC VIEWS • HOLISTIC VIEWS
• Mental health & illness as • Mental health & illness as
fundamentally unique and inseparable and
separate from physical interdependent from physical
• Emphasizes predispositions • Emphasizes toxic war stress
and weakness as causal as primarily causal
• Questions authenticity • Authenticity equal to physical
• Perpetuates stigma • Reduces stigma
• Under-values mental health • Parity in priority, value and
science and treatment resources toward mental
• Justifies disparity in priority, health science and treatment
resources and compensation • Ensures cost effective
• Ensures cost ineffective integrated healthcare
fragmented healthcare

Common Myths Underlying
Dualistic Predisposed War Hysteria
• Myth 1: Pre-20th century chronic post war
disorder was rare (culture of trauma)
• Myth 2: Non-combatant breakdown is proof
of predisposed war hysteria
• Myth 3: The vast majority (90%) of acute
breakdown recover
• Myth 4: Resiliency is overwhelming (90%)
normative response to war-thus chronic post
war disorder is generally proof of
predisposition

Debunking Myth 1: Historical Evidence of
War Stress Injuries prior to 20th Century

Evidence of 18th Century War Stress
Injuries and Etiology
• 460-350 B.C. Hippocrates - Greek
physician, ‗father of Western
medicine‘
• Rejected supernaturalism
• Holistic concept of mental illness
(melancholia, hysteria, mania,
phrenitis, inebriety)
• Etiology attributed to brain pathology
and life style factors
• 129-200 A.D. Galen - prominent
Roman physician extended
Hippocratic materialistic etiology of
mental illness
• 460-350 B.C. Hippocrates “Whenever
people of the mountains or plains or
prairies were sent to another country,
a terrible perturbation always followed
them” (McCann, 1941)

Evidence of 18th Century Post War
Disorder: ‗Nostalgia‘
• 1678 –Swiss physician Johannes Hofer
described ‗Nostalgia‘ or pathological
homesickness - as first identified post
war disorder
• ―Men of all temperaments, weak and
strong, are more or less susceptible‖
(Hofer, 1678)
• 1678- Holistic etiology -―Nostalgia is
due essentially to a disordered
imagination, whereby the part of the
brain chiefly affected is that in which
the images are located‖ (Hofer, 1678)
• 1774 – Jasper reported 1,000 of Scottish
English, Laplander, Celts, French, &
Austrian soldiers dying of the
‗homesickness disease‘

Evidence of 19th Century Post War
Disorders: Crimean War (1854-1856)
• 1854-1856- 2,561 Russian soldiers
admitted at one military hospital
for ‗nervous exhaustion‘
disorders

• 1859-Russian Military Medical
Academy-established to train
Russian military psychiatrists
and research post war disorders

• 1863-Royal Victoria Hospital in
Netley, England created for
functional heart disorders

• 1867-Maclean studied 5,500
Crimean War veterans with
‗irritable heart‘

Etiologic Views in Pre-1945 Russian Army
• History of Russian military and psychiatry
closely intertwined (Wanke, 2005).
• 1706- Peter the Great established a clinic in
Vyborg to care for mentally exhausted
soldiers.
• 1761- specialized psychiatric hospitals were
established by Catherine the Great providing
humane treatment for mentally ill Russian
veterans.
• Materialistic etiological concepts embraced
by Russian Medicine, led by Ivan Pavlov-
mental and emotional reactions as
physiologically inseparable from the nervous
system or brain.
• Etiology-war stress injuries are predictable
and primarily caused by pathogenic (toxic)
environmental war stress effects on the
nervous system

Women Pioneers in Treatment
of Post War Disorders
• 1856-Flourence Nightingale –
Humane treatment of Crimean
War veterans suffering post war
disorder

• 1848-Dorothea Dix –Mental
Hygiene Movement. In 1852, the
U.S. Congress established The
Government Hospital for Insane
in Washington D.C., to provide
―the most humane care and
enlightened curative treatments
for the insane of the Army and
Navy.‖ Appointed Chief Nurse,
Union Army

Evidence of 19th Century Post War Disorders:
American Civil War (1861-1865)

Conflict Country Casualty Rates NP/MUS Pensions
Admissions

U.S. Civil War Union KIA: 140,414 Acute Rheumatism WIA/injuries
(1861-1865) (2,213,363) WIA: 281,881 (145,000) (117,947)
Confederate Death by disease: Chronic Rheumatic Chronic diarrhea
(1,050,000) 224,097 (109,000) (55,125)
Deserters: Mental Aches Diseases of Heart
200,000 (50,000) (25,994)
KIA: 74,524 Nostalgia (5,200) Rheumatism (40,790)
WIA: Unknown Functional Neuralgia (2,144)
Death by disease: constipation Epilepsy (1,512)
164,000 (150,000) Disease of
Deserters: Irritable Heart brain/insanity
100,000 (10,636) (1,098)
Dropsy (2,224) Nervous prostration
Insanity (1,231) (5,320)

Etiologic Views of War Stress Injuries:
American Union Army (1861-1865)
Union Army Surgeon General William A.
Hammond adopted a holistic, ‗mind-body
unitary theory‘ of war stress injuries
1862- Established the ‗U.S. Army Hospital for
Diseases of the Nervous System‘ in
Philadelphia (known as Turner Lane)
dedicated to the research and treatment of
‗nervous disorders‘
Viewed ‗nervous disorders‘ as legitimate,
morally indistinguishable from war wounds.
S. Weir Mitchell developed the ‗resting cure‘, a
precursor to frontline psychiatric intervention.
1864 Jacob Da Costa‘s published first study of
treating 200 soldier‘s with ‗irritable heart.‘
1883 Hammond - quot;The brain is the chief organ
from which the force called the mind is
evolved, and, so far as the present treatise is
concerned, may be regarded as the only
one…either in health or disease‖ (p. 9) adding
―The connection between the mind and brain
is not doubted at the present day, although the
character of the relation is still the subject of
controversy ―(p. 10).

History of the ‗Trauma and Pension Wars‘
• ―Trauma‖ Greek - physical wound began to
be applied to ‗psychical‘ injuries suffered by
victims of railway accidents in North America
and Europe in the 1860-70s.
• 1889 -1 of 117 train workers killed and 1 of 12
injured in accidents
• 1864 - British physician John Ericksen
classified first holistic, post traumatic stress
condition – ‗Railway Spine‘
• ―It must be obvious that in no ordinary
accident can the shock be so great as in those
that occur in Railways. The rapidity of the
movement, the momentum of the persons
injured, the suddenness of its arrest, the
helplessness of the sufferers, and the natural
perturbation of the mind that must disturb the
bravest, are all circumstances that of necessity
greatly increase the severity resulting to the
nervous system‖ (Ericksen, 1864)

Traumatic Neurasthenia
• 1869 -American physician
George Beard- coined the
term „neurasthenia‟
• Holistic condition caused by
depleted „nerve force‟ from
adapting to modern
urbanized society or
traumatic events
• Quickly adopted in Europe
• Mitchell‟s „resting cure‟ was
treatment of choice

Traumatic Hysteria: Holistic Paradigm of
Predisposed Post-Traumatic Disorder
• 1870‘s- Jean M. Charcot keenly interested in
‗male hysteria‘ at Salpetreiere Hospital in
Paris, France.
• Using ‗auto-suggestion‘ or hypnosis
including veterans from the Franco-Prussian
War (1870-1871)
• Intense affect combines with individual
predispositions, a process he labeled
‗diathese‘ to produce, holistic ‗hysterie
traumatique‘ (traumatic hysteria).
• Subsequently, Pierre Janet and Sigmund
Freud extended Charcot‘s predisposition
theory of traumatic hysteria by emphasizing
early life experiences over the direct
environmental effects of traumatic events

Traumatic Neuroses:
Traumatic Events as Causal
• 1888-Prominent German neurologist
Hermann Oppenheim, Director of
the Neuropsychiatric Clinic at the
Charite
• Disagreed with ‗predisposed
traumatic hysteria‘ - controversial
lecture published in 1889 introducing
―Die Traumatischen Neurosen‖ (The
holistic, Traumatic Neuroses),
attributing primary causation to brain
injury from traumatic stress
• ―The abnormal excitability of the
cardiac nervous system is an almost
constant symptom of traumatic
neurosis‖

Initial Resolution of the Mind-Body Debate:
Holistic Post Traumatic Stress Disorder
• 1864 -British Legislative Act of made
railway companies liable for ‗railway spine‘
injuries (Glynn, 1910) subsumed under the
broader category of ‗traumatic neuroses‘
and extended to other work-related
accidents (‗accident neurosis‘)
• 1880-British Employers Act
• 1897-British Workmen‘s Compensation
• 1889 -German Imperial Insurance Office
Act followed British legal precedent
granting ‗traumatic neuroses‘ the status of
‗actionable conditions‘ by extending the
1884 Accident Insurance Law (Brunner, 2003).

The Growing Trauma-Pension
Debate
• 1910 – Thomas Glynn‘s seminal forensic
review of post traumatic disorders.
• ―Traumatic neurasthenia (traumatic
neurosis) has come to be recognized by
lawyers as indicative of a definite disorder
produced by accident and on the other hand,
the term hysteria to the unprofessional, is
suggestive of malingering‖ (p. 1333)
• ‗Pension Neurosis‘ (Rentenneurose)

Evidence of Early 20th Century Post War
Disorder : The Boer War (1899-1902)
• 1900 - British Army surgeon
Morgan Finucane reported
symptoms in soldiers ―akin to
nervous shock or those observed
after railway accidents‖
• Sample of 6,276 war pensions
• 15% (964) diagnosed with post
war disorder
• Debility (392) – 20,767
• Functional Rheumatism (272) –
24,460
• Disordered Action of Heart
(DAH; 199) – 3,631
• Psychosis (27)
• Sunstroke MUS (21) - (Jones &
Wessley, 2005)

Evidence of Early 20th Century Post War
Disorder: Russo-Japanese War (1904-1905)
• 24% (2,309) of all Moscow
military hospital admissions
diagnosed- ‗nervous
exhaustion‘

• 12,753 Russian NP admits to
Central Harbin hospital

• Unprecedented - Russian
military hospital Central
Harbin diagnosed at least
2,000 cases of ‗traumatic
neurosis‘ directly attributed to
war stress (Wanke, 2005)

The Rise of Dualism and Hysteria
• 1905-Joseph Babinski replaced
Charcot and holistic traumatic
hysteria with dualistic
predisposed hysteria as ―the
sum total of the symptoms
that can be called forth by
suggestion and dispelled by
counter suggestion‖ such as
• 1911-Robert Gaupp- hysterics psychotherapy (Cited in Marlowe,
―lacked a firm mechanism of 2000; p, 21).
inhibition seen in particular
women, effeminate men, • War hysteria became a disease
children, the uneducated, of the ‗will‘
and those outside Western
Europe who were more likely
to lose self-control and react
to stimuli by ‗fleeing into‘
hysterical symptoms‖
• (Cited in Lerner, 2003; p. 38).

The Rise of Dualism and Hysteria
• 1886 – Bernhard published sexual
crimes survey of 36,176 German girl
• 1893 –Breuer & Freud‘s ‗Studies of
Hysteria‘ adopt Janet‘s tenet of
dissociation from trauma
• 1896 – Freud cited sexual trauma as
cause for hysteria in ‗Aetiology of
Neurosis‘
• 1896 – ‗Aetiology of Hysteria‘ Freud
adopted dualistic concept of hysteria
emphasizing repressed impulses and
secondary gain vs. traumatic events
as causal
• Psychoanalytic views became
predominant during WWI and WWII

1864-1905: The Reign of Holistic
Paradigm of Post Traumatic Disorders
• Major difference between post traumatic classifications was
degree that predisposition was emphasized.
• Significant overlap of diverse psychophysical symptoms
• „Traumatic hysteria‟ as described by Charcot, Janet and
Freud initially- generally adopted holistic view of
symptoms and suffering along with „traumatic neurosis‟
and „traumatic neurasthenia.‟
• Both „traumatic neurosis‟ and „neurasthenia‟ classifications
included sub-group of holistic predisposed traumatic
hysteria

1912: Framing the Mind-Body Dichotomy
and “Trauma-Pension‟ Debate
Kay (1912) analyzed war-stress impact from 1886 to 1908 for the British
Army finding significant associations between increased rates of post war
disorders and duration of war stress ―the amount of the increase is
proportional to the duration of campaign‖ (Kay, 1912; p. 153)

Intensity of combat exposure ―The conditions of modern warfare calling
large numbers of men into action, the tremendous endurance, physical and
mental required, and the widely destructive effect of modern artillery fire‖
(Cited in Jones & Wessely, 2005; p. 13)

Forewarning military leaders about the toxic effects of 20th century
warfare ―we shall have to deal with a larger percentage of mental disease the
hitherto‖ (Cited in Jones & Wessely, 2005; p. 13)

Conversely, WWI German Army psychiatrist Robert Gaupp predicted
―only a small percentage succumbs and takes flight into sickness‖ (Cited in
Lerner, 2003; p. 40)

The First World War (WWI: 1914-1918)

Extending the Trauma-Pension, Mind-Body
Debate to Post War Disorders
• December 1914, widespread post war disorders appeared even in seasoned
Allied and German military officers and enlisted leaders, including an estimated
10% of British officers and 4% of enlisted personnel
• 1914 Berlin Society of Psychiatry and Nervous Illness meeting, Oppenheim
concluded ―The war has taught us and will continue to teach us (1) that just as
before there are traumatic neuroses; (2) that they are not always covered by the
concept of hysteria; and (3) that they are really the product of trauma and not
goal-oriented, well cultivated pseudo illness ―
• Gaupp, a staunch advocate of dualistic predisposed hysteria stated ―the most
important duty of the neurologist and psychiatrist is to protect the Reich from
proliferations of mental invalids and war pension recipients‖
• Alfred Hoch (1915) levied charges against insurance doctors awarding war
pensions as responsible for epidemic of nervous weakness, ―The individuals are
in fact sick, but they would be well, strangely enough, if the law did not exist‖

Difficulties Estimating Actual Prevalence
of Post War Disorders
• American Civil War- estimated 300,000 deserters between Union and
Confederate armies
• 3,080 WWI British soldiers sentenced to death for cowardice, desertion or
malingering with an estimated 300 executed.
• American Army psychiatrists in Korea-as incidence rates of frost bite rose
number of NP casualties decreased (self-inflicted wounds)
• 42 of 75 (56%) Korean War vets on orthopedic wards reported NP symptoms
via impromptu psychiatric interview
• 2003, a Navy Fleet Hospital screened 1,341 (97%) OEF/OIF medically
evacuees finding 377 (30%) with ASD, PTSD, or depression
• Widely-varying, non-standardized diagnostic labels
• Military policy to avoid psychiatric labeling
• Blurring between diagnosing organic versus functional somatic syndromes
(i.e., cardiovascular defect vs. soldier‘s heart)
• Unbridled stigma and disparity exemplified by battlefield executions for
inability to continue the fight, public ridicule (i.e., ‗psycho,‘ ‗lacking moral
fiber‘ -2,989 RAF) and imprisonment (e.g., 900 Union Army courts-martial).

Shell Shock and Demise of Holistic
Paradigms • French ‗la confusion
1915- British psychologist mentale de la guerre,‘
Charles S. Myers published
case studies of ―shell German ‗kriegsneurose‘
shocked‖ soldiers suffering • Public media and
diverse psychophysical sxs increased prevalence
Holistic etiology - ―an caused outrage
invisibly fine molecular
commotion in the brain‖ amongst war planners
(TBI-today)
-1916 - Germany‘s artillery
barrage at Verdun -100,000
shells an hour
- 1916 -Allies‘ 1,500,000 shells
during 5-mo. ‗Battle of the
Somme‘ resulting 6,000
‗shell shock‘ cases per
month

WWI German Total Nervous disease: (613,047)
(1914-1918) (11,000,000) -Nervous illness; Rheumatism
-Cardiac neuroses
Shell shock (80,000); DAH (41,699)
Gas hysteria-80 of 96 (83.3%) gas casualties sampled

British Total NP: 200,000 –(1929)
(8,904,467) -DAH (42,948),Effort syndrome (35,000)
-VDH (21,706)
-Rheumatism (28,983)
-Functional Nervous (11,443)
-Epilepsy (6,388)
-Shell shock (18,596)
-Neurasthenia (55,469); Insanity (12,000 in 1930)

American Total NP: 69,394
(4,355,000) -Psychoneurosis (11,443)
-Shell shock (63)
-Neurocirculatory asthenia (1,737)
-Nervous diseases and injuries (6,916)
-Epilepsy (6,388)
-Endocrinopathies (4,805)
-Psychosis/mental disease (7,910)
-Inebriety (alcohol/drugs) (3,878)
-Mental Defect (21,858)
-Constitutional psychopathy (6,196)
Russian Total: 102,566
(12,000,000) -Nervous illness (81,154)

The 1916 Medico-Scientific Political Coup:
End of Holistic Post War Disorder Paradigm
• September 1916- Munich War Congress of the
German Association for Psychiatry and Neurological
Association
• Medical history by replacing holistic post traumatic
disorder paradigm with dualistic, predisposed war
hysteria and end trauma-pension debate
• 1916 - German military outlawed holistic ‗traumatic
neurosis‘ (i.e., shell shock), adopted aggressive
frontline measures to end ‗hysteria‘ and cowardice
• 1916-British Army Council replaced ‗shell shock‘ with
‗Not Yet Diagnosed Nervous‘ (NYDN)-adopted
aggressive frontline psychiatry and policies to end
hysteria, cowardice and malingering
• 1917- American Expeditionary Forces entered WWI-
avoiding holistic diagnoses. Salmon (1917)
implements frontline ‗PIE‘ similar to French &
British to ‗conserve the fighting force‘

Post-WWI Mental Health Crisis
(P. Bailey; The New York Times; September 14, 1919)


Published: June 2, 1922

Published: September 9, 1923

Post-WWI Mental Health Crisis Published:
June 30, 1935

The Trauma-Pension and Mind-Body
Wars from 1916 to 1943
• After WWI, every major military power conducted investigations
into causes of the ‗dishonorable‘ epidemic of war hysteria with
moral outrage of paying pensions to large masses of un-
deserving vets.
• Urgent mission was to ensure there would never be a repeat of
the universally condemnable ‗war hysteria‘ in future wars

The Enemy Within: Eliminating Dualistic
War Hysteria and the ‗Culture of Trauma‘
• 1926, the German National Pension
Court and Imperial Insurance Office
reversed its 1889 decision-officially
rejecting traumatic neurosis as
actionable.
• 1939 Nazi Germany flatly outlawed post
war disorders as a run up to WWII under
the potential punishment of death
• War stress injuries universally viewed as
illegitimate ‗dualistic predisposed
hysterical‘ conditions ineligible for
compensation as ‗imaginative‘ illness
(Brunner, 2003).
• Japanese military government mandated
destruction of all military mental health
records (Matsumura, 2005).

The Enemy Within: Eliminating Dualistic
War Hysteria and the ‗Culture of Trauma‘
• 1920- British War Office Committee of Enquiry - established due to
socio-political concerns from veterans over treatment and
compensation (Leese, 2002).

• The Commission attributed blame for war hysteric masses as result
of poor recruit screening of inherently predisposed or defective
personnel, low unit morale and training, cowardice and
malingering-greatly exacerbated by psychiatric labels like ‗shell
shock‘ that inadvertently provided honorable grounds to escape
duty

• By 1939-Britain kept only six military psychiatrists on the payroll.

• 1942 British Prime Minister, Winston Churchill, ―I am sure it
would be sensible to restrict as much as possible the work of these
gentlemen (Army psychiatrists), who are capable of doing an
immense amount of harm with what may very easily degenerate
into charlatanry. The tightest hand should be kept over them, and
they should not be allowed to quarter themselves in large numbers
upon the fighting services at the public expense‖ (Cited in Jones &
Wessely, 2005; p. 116).

Eliminating Dualistic
Predisposed War Hysteria
and Culture of Trauma
• 1927-Efforts to disband military mental health services began were completed by 1937 as reflected in
the revised 685-paged U.S. Army‘s ―Handbook for the Medical Soldier‖ containing only a single
page dedicated to treating war stress and a handful of military psychiatry advisors on the payroll
(Wanke, 2005).
• 1941-Harry Sullivan appointed as U.S. Army psychiatric consultant to the Selective Service
• 1941 - Orr reported the objectives of NP screenings was to disqualify the obviously ‗psychopathic‘ or
psychiatrically unfit then ―eliminate further: (1) those men with more subtle personality disorders
missed by previous examiners; (2) men whose present personality makeup suggests that they may
break under the special stresses and strains of camp life; and even beyond these, (3) men who may
be expected to develop some type of neuropsychiatric disorder at any time during the next eleven
years ―
• 1941 to 1943 rejected 1,680,000 ‗predisposed hysterics‘ or remotely defective inductees.
• However over 1,103,000 Army and 150,000 Navy/Marine Corps NP casualties resulting in 504,000
(72%) supposedly non-defective Army and 100,000 (67%) Navy/Marine Corps personnel
psychiatrically discharged
• 248 veterans previously disqualified followed-up one year after induction with 209 (84%) still on
active duty; 32 discharged (2 accepting officer commissions) and 5 killed in action
• 1943-Chief of Staff, General George C. Marshall – abandoned the failed social-experiment which
empirically disproved the predominant paradigm of dualistic, predisposed war hysteria.

World War II (1939-1945)

• 1939 – U.S. Army disbanded psychiatry units – emphasis
screening out the mentally and intellectual deficient
recruits prone to crack
• 1,680,000 registrants classified as ―unfit‖ due mental
disease or educational deficiency
• 1943 – Capt Phil Hanson ―rediscovered‖ PIE returned
rate of 70%
– Guadalcanal: 1MARDIV had 40% of casualties
disabled by combat stress
– Okinawa: 1:2 disabled by combat stress

Paradigmatic Compromise for Dualistic
Predisposed Post War Disorders
• 1943- Western paradigm emerged re-interpreting ‗acute‘
symptoms and ‗acute‘ post - war disorder as
predictable, ‗universal‘ and holistic-but short-lived
human stress reactions
• Consequently, since WWII- Western militaries
emphasize non-pathological terms for acute stress
breakdown, ‗battle or combat fatigue,‘ ‗flier‘s fatigue,‘
‗battle or combat exhaustion,‘‘ ‗operational fatigue,‘
‗combat-stress reaction‘ and contemporary ‗combat and
operational stress reaction,‘
• De-pathologizing ‗acute‘ stress reactions and
temporary breakdown by avoiding psychiatric labeling
and military separation unless combatants did not
recover
• 1958 Beebe & Appel. ―One of our cultural myths has
been that only weaklings break down psychologically
(and that) strong men with the will to do so can keep
going indefinitely‖ (p. 164)
• **However- chronic war stress injury was viewed as
evidence of dualistic predisposed war hysteria and/or
secondary gain

Maintaining Dualistic War Hysteria
Paradigm in ‗Chronic‘ Post War Disorder
• 1946 – ‗Infamous slap‘ of ‗battle fatigued‘ soldier by
General George C. Patton, USA, Palermo, Italy

• 2003 British High Court, MoD‘s experts testified,
―psychiatric thinking for most of the 20th century
was of the view that the determinants of prolonged
psychiatric disorder are established in early life,
either by genetic or developmental processes‖ and
that ―breakdown would be short lived. If this was
not the case then the cause was not really the war at
all, but a person‘s predisposition and personality‖
(McGregor et al., 2006; p. 22).

• ―Before the 1970‘s, anyone who suffered long-term
effects after a frightening event was considered
constitutionally predisposed to mental illness or
subject to a repressed childhood trauma; in either
case, responsibility lay with the individual‖
(Jones and Wessley, 2007)

Conflict Country Casualty Rates NP/MUS Rates Per NP/MUS Admissions
1,000
WWII German KIA: 3,500,000 Total: 472,250 ‘war neurotic’
(1939-1945) (17,900,000) WIA: 5,000,000 -3-5% of all hospital admissions
were NP only

American KIA: 291,557 20-30 per 1,000 NP only Total: 1,253,067 – NP only
(16,112,566) WIA: 671,846 60-70 per 1,000 Army: 1,103,067 –NP only
(1:19- NP:WIA) (Southwest Pacific Navy/Marine Corps: 150,000-NP
theater) only-34% of total admits
38.3 per 1,000
(European theater)
-43.5 per 1,000 (Army
only)

British KIA: 326,000 British 2nd Army Total: 409,887 NP only
(5,986,000) WIA: 277,077 (200 per 1,000) during -Dyspepsia-largest single cause of
Normandy medical invalidity 1939-40; 17%
NP only: 6-10 per 1,000 all medical discharges in May
(1:38; NP:WIA) 1942
- ‘Lacking morale fiber’ (2,989) in
R.A.F.

Russian KIA: 1,297,954 Total: 1,007,585 NP
(22,000,000) WIA: 1,166,615 (26.6% NP of all hospital
admissions)

Japanese KIA: 1,300,000 Total: 10, 454 NP
(9,100,000) WIA: 4,000,000

Post-WWII Mental Health Crisis

Published: August 6, 1944

Post-WII Mental Health Crisis

Published: July 12, 1944


Published: February 15, 1946

(H. Rusk; The New York Times; November, 16, 1947)

Overview of Mind-Body Dualism
and the ‗Trauma-Pension Wars‘
• 1952-DSM-I. Post-WWII research
on stress reactions led to the
diagnostic formulation of ‗gross
stress reaction‘ in the first DSM
(APA, 1952).
• 1968-DSM-II, ‗transient situational
disturbance‘ was adopted with a
similar conceptualization of the
holistic pathogenic effects of
overwhelming stress (APA, 1968).
• 1980-DSM-III-‘PTSD‘ first
diagnosis since 1864 ‗traumatic
neuroses‘ attributing etiology to
traumatic stressors vs. predisposed
hysteria

Korean War (1950-1955)
―The Forgotten War‖

• 55,000 veterans died in Korea
• No major studies on Korean War veterans
• DoD provided frontline MH and triage system
• Estimated 30% of U.S. troops have full or partial
PTSD, high incidence of substance abuse

• Least likely to utilize VA health services

Post-Korean War Mental Health Crisis

Work Centers Proposed for 'Goldbrickers'
By Nate Haseltine Staff Reporter
The Washington Post and Times Herald (1954-1959); Dec 1,
1954; ProQuest

The PTSD Debate Enters the Trauma-
Pension Wars: Vietnam War (1964-1975)
• 1988- Congressionally
Mandated National Vietnam • 38% divorced within 6-
Veterans Readjustment Study months
(NVVRS)
• Lifetime prevalence PTSD = • 40% homeless men; 15%
30% (1.7 million vets) unemployed
• 15.2% males (450,000) and • Mortality - 65% more
8.5% females (610), have
current PTSD. likely suicide; 48% MVA
• 30% of WIA have current
PTSD
• 50-60% co-morbidity

Post-Vietnam War Mental Health Crisis

Panel Says Delayed Fear Grips Vets
By Stuart Auerbach Washington Post Staff Writer
The Washington Post, Times Herald (1959-1973); May 3, 1972;
ProQuest

Debunking Myth 2:
Empirical Evidence of Stress and Health
• General William C. Menninger, Office of Surgeon General, U.S. Army
(1947)- ―except for … a …[small]… group of psychologically and
scientifically minded physicians, it has required …a second World War to
acquaint the people with the actuality of psychosomatics‖ (p. 93).

• Seyle and Fortier (1950) ―The nervous system is particularly sensitive to the
effects of systemic stress‖

• ―combat intensity is the greatest battlefield predictor of stress reactions. In
general as the number of physical casualties rise, so will the numbers of
CSRs‖ (Helmus & Glenn, 2005; p.32),

• Recent meta-analyses of 50 brain imaging studies on PTSD revealing
structural abnormalities in multiple frontal-limbic brain areas associated
with PTSD (Karl, Schaefer, Malta, Dorfel, Rohleder & Werner, 2006).

• Empirical review of 11 neuroimaging psychotherapy studies on mood and
anxiety disorders, including PTSD-indicates significant changes in brain
function coinciding with symptom reports following successful treatment
(Frewen, Dozois & Lanius, in press).

OPERATION DESERT STORM
(1991)

-Post-deployment status: Few days
after return to CONUS, PTSD rate was
3.2% (males); 9.6% (females)
-18-months Post-deployment: PTSD
rate increased 9.4% (males); 19.8%
(females)
- Handling human remains – PTSD
rates of 48% current; 65% lifetime

-Congressional Gulf War Studies

-1998 PL 105-277 Persian Gulf War
Veterans Act
-1998 PL 105-368 Veterans Programs
Enhancement Act

Congressional Gulf War Studies on
Health Effects of War Stress
• ―In response to
deployment-related stress,
physiologic changes occur
in the body, may persist for
a long time after
deployment has ended, and
may result in symptoms
and disorders that appear
soon after exposure to the
stressor or become evident
only years later.‖ (IOM,
2008; p. 66).

Congressional Gulf War Studies:
Chronic Health Effects of War
• ―Activation of the stress response ensures
survival in the short term, but is maladaptive
when its activation persists as a result of
chronic, severe, or repeated stress‖ (IOM,
2008; p. 59).
• ―Chronic stress can lead to adverse health
outcomes that affect multiple body systems
such as the CNS, endocrine, immune,
gastrointestinal and cardiovascular
systems.‖ (IOM, 2008; p. 59)

Debunking Myth 3: Recovery after Acute
Breakdown is Normative
• Reviews of efficacy of frontline psychiatry- 78-85% of troops not
restored to full-duty (Jones & Wessely, 2003)
• 1944- ‗Restricted‘ report of restoration rate between 16-32% (Sandiford,
1944a)
• 1944- ‗Secret‘ classified study reports 43% relapse (Sandiford, 1944b)
• 1943 -‗Restricted‘ report, ―of patients returned to duty, how many
go back to combat? We have no figures with which to answer the
question, but can make a fairly good estimate—it is less than 2.0
per cent!‖ (Grinker & Spiegel, 1943).
• 1943 -―over 70% can be rehabilitated for selective non-combatant
service, in quiet sectors‖ (Grinker & Spiegel, 1943)
• 2003- British High Court upheld the MoD‘s defense ruling ―Given
this relative absence of reliable evidence as to their therapeutic
effect there was a further question mark over whether or not it was
even ethical to implement the principles of forward psychiatry at
all‖ (McGregor et al., 2006; p. 25).

Common Myths Underlying
Dualistic Predisposed War Hysteria
• Myth 1: Pre-20th century chronic post war
disorder was rare (culture of trauma)
• Myth 2: Non-combatant breakdown is proof
of predisposed war hysteria
• Myth 3: The vast majority (90%) of acute
breakdown recover
• Myth 4: Resiliency is overwhelming (90%)
normative response to war-thus chronic post
war disorder is often proof of predisposition

Predispositions and Risk Factors in
General and Mental Health
• 2003 MoD PTSD Case-
‖psychiatric thinking for
most of the 20th century
was the view that the • ―What is most important
determinants of prolonged to reiterate is that the
psychiatric disorder are causes of health and
established in early life.‖ disease are generally
viewed as a product of the
interplay or interaction
• ―Breakdown would be between biological,
short-lived. If this was not psychological and socio-
the case then the cause cultural factors. This is
was not really the war at true for all health and
all, but a person‘s illness, including mental
predisposition and health.‖ (American
personality‖ (McGregor et Surgeon General, DHHS,
al., 2006; p. 22) 1999)

‗Old Sergeant‘s Syndrome‘

Old Sergeant‘s Syndrome
• 1949 -Sobel studied 100 seasoned noncommissioned officers ‗old‘ in combat
experience identified with ―old sergeant syndrome,‖ or ―Guadalcanal twitch‖ a
constellation of chronic psychophysical symptoms in well-motivated, combat-
tested, invaluable soldiers and leaders

• ―For these men were among the best and most effective of the trained and
disciplined combat infantry soldiers‖ (Sobel, 1949, p. 137)

• 2nd Lieutenant Audie Murphy (1924-1971), depicted in the 1949 movie, ‗To
Hell and Back‘, is the American military‘s most highly decorated WWII soldier
receiving 33 awards for bravery including the Medal of Honor, after fighting in
9 major European campaigns, and being WIA three times- suffered publicly
from severe ‗battle fatigue,‘ insomnia and depression symptoms consistent
with PTSD (http://www.audiemurphy.com).

• ‗Flier‘s fatigue‘ ‗operational fatigue‘ was vividly illustrated in the 1949 movie
‗Twelve O‘ Clock High‘ with fewer than 25% completing a full tour of duty
(Chermol, 1985).

Current Paradigm of Post War Disorders in
21st Century Military Medicine
• 8/18/08: ―Of the 10 percent or so who have PTSD,
most will recover with time, patience and
love. Some will need more.‖ (S. Ward Casscells, M.D.;
ASD(HA), MHS.blog)

• 8/18/08: ―Services altering strategy on
PTSD…that treats such ailments (PTSD) as
temporary instead of lifelong problems‖ (Stars
& Stripes, 2008)

• 8/18/08: ―In the past, we thought if a
Marine had PTSD, he was gone. Now it‘s
more like breaking a leg.‖ (SGTMAJ Wilson, Personal and
Family Readiness Division, S&S, 2008)

DVA/DoD Public Health Model
• Most war fighters/veterans will not develop a
mental illness but all war fighters/veterans and
their families face important readjustment issues
• This population-based approach is less about
making diagnoses than about helping individuals
and families retain a healthy balance despite the
stress of deployment
• Incorporates the Recovery Model and other
principles of the President‘s New Freedom
Commission on Mental Health
– There is a difference between having a problem and
being disabled

PTSD and Current U.S. Army
‗Textbook of Military Medicine: War
Psychiatry‘
• ―Chronic PTSD symptoms develop in those with
social and biological predispositions in whom the
stressor is meaningful when social supports are
inadequate‖ (Jones, 1995; p. 416).

• ―Other mechanisms such as positive
reinforcement (secondary gain in Freud‘s model)
seem more important in the chronic maintenance
of symptoms‖ (Jones, 1995; p. 417).

Resistance to Scientific Change and EMDR:
A Case Study of Dualism and Disparity in the
Armed Services

Progression of Science and Prominence
• Scientific resistance to
innovation or change is
necessary has an adaptive
function

• In psychology,
prominence is relative to
whichever theory is
currently favored by the
broader scientific and
intellectual community as
opposed to specific
school‘s ability to
document scientific truths
(Tracy et al., 2005)

VA/DoD CPG and EMDR
• ―Overall, argument can reasonably be made that
there are sufficient controlled studies that have
sufficient methodological integrity to judge EMDR
as effective treatment for PTSD‖ (pg. 5).
• ―Foa et al (1995) note that exposure therapy may
not be appropriate for use with clients whose
primary symptoms include guilt, anger, or shame‖
(pg. 4).
• ―EMDR may be more easily tolerated for patients
who have difficulties engaging in prolonged
exposure therapy‖ (pg. 2).

VA/DoD CPG and EMDR
• ―The possibility of obtaining significant clinical
improvements in PTSD in a few sessions presents this
(EMDR) treatment method as an attractive modality
worthy of consideration‖(pg 1)

• ―EMDR processing is internal to the patient, who does not
have to reveal the traumatic event‖ (pg 1).

• ―EMDR has been found to be as effective as other
treatments in some studies and less effective than other
treatments in some other studies‖ (pg 9 summary).

Domestic and International PTSD
Treatment Practice Guidelines:
EMDR as EBT-PTSD
• American Psychological • DVA/DoD (2004)
Association, Division 12 • American Psychiatric Association
(Chambless et al., 1998) (APA, 2004)
• International Association for • U.K.‘s National Institute for
Traumatic Stress Studies (Foa, Clinical Excellence (NICE, 2005)
Keane, & Friedman, 2000) • International Cochrane Review
• United Kingdom Department of (2007)
Health (2001) • International Studies of Traumatic
• Israeli National Mental Health Stress Society (2007)
Council (Bleich, Kotler, Kutz, &
Shalev, 2002)
• Northern Ireland Department of
Health (2003)
• Dutch National Steering
Committee for Mental Health Care
(2003)
• French National Institute of Health
and Medical Research (2004)

Domestic and International PTSD
Treatment Practice Guidelines:
EMDR as non-EBT-PTSD
• VA commissioned
Institute of Medicine
(2007) review

Restricted Access to EMDR
Training in DoD
• Center for Deployment
Psychology (2007)-
mission train DoD
interns/residents
• VA‟s National Center-
PTSD-mission train
DVA/DoD
• No EMDR training
• Army Medical
Department (AMEDD)-
offering limited EMDR
training since 2008

DoD/VA Regional PTSDTraining Project
(Russell, Silver, Rogers, & Darnell, 2007)
Dates of Training Location #MH providers trained

12-13 Jan 05 (part I) PACNORWEST region. Ft. 70 total: (DoD = 60; VA =
Lewis Army Base, WA 10)

28 Jan – 4 Feb (part I) NH Great Lakes, MI 10 total: (DoN)

8-10 Apr 05 (part I) NAS Brunswick, ME 8 total: (DoD)

19-20 Apr 05 (part I) NH Bremerton, WA 10 total: (DoN/DoA)

4-5 May 05 (part II) PACNORWEST Region, Ft. 62 total: (DoD = 57;
Lewis Army Base, WA VA = 5)

9-10 May 05 (part I) NMCSD, San Diego 15 total: (DoN)

Aug 05 (part I & II) NH Camp Pendleton, CA 12 total: (DoN)

Sep 05 (part I & II) Ft. Hood, TX 70 total: (DoA)

Total of 10 *257 total
Trainings participants

EMDR Treatment Outcome: Combat-PTSD
Mean # sessions = 4.3 (n = 48)

9 8.5
8
7 6.8
6
5
SUDS
4
VoC
3
2.2
2
1.2
1
0
Pre-tx Post-tx

EMDR Treatment Outcome: Combat PTSD
Impact of Events (IES) & Beck Depression
Inventory (BDI) (n = 48)

70
61
60
50
40
IES
30 BDI
20 20
20
10 4.2
0
Pre-tx Post-tx

Banning of EMDR Research in DoD
(Russell & Friedberg, 2008)

• $300 million to study PTSD
E M D R T reatm ent For C om bat R el
ated
S tress and TBI (USA Today, 8/5/08)
50 • 2007-DoD‘s ‗Center of
45
40 Excellence for Psychological
35
Health and Traumatic Brain
30
25 Injury‘ in Arlington, VA
20
15
• 28 March 2008 key word
10 search of PILOTS PTSD
5
0
dbase:
P re I
ES P ost IES
P ati 1
ent
ent
P ati 2
31
38
5
15
• CT = 1096
42 8
P ati 3
ent
P ati 4
ent 44 10 • EMDR = 533

National PTSD Research
• Question: ―The number of
• A 28 March 2008 key word references to EMDR
query of NIMH‘s PTSD research in the NIMH‘s
Research dbase dbase is:‖
• CT – 638 • (a) 2
• CBT – 255 • (b) 12
• Behavior Therapy – 641 • (c) 50
• (d) 105
• Correct answer:
• (a)
RCT favorably comparing
EMDR to Prozac and
placebo (van der Kolk et
al., 2007)

Mental Health Disparity in
Federal Research

Veteran‘s PTSD Research
• A 28 March 2008 key word • Question: ―The number of
query of VA‘s National references to EMDR
Center for PTSD Research research in the NC-
dbase:
PTSD‘s dbase is:‖
• CT – 76 • (a) 0
• BT – 30 • (b) 9
• ET – 27 • (c) 18
• (d) 27
• Correct answer:
• (b) – 9, but only 2 actual
research articles found

Military PTSD Research
• A 28 March 2008 key • Question: ―The
word query of DoD‘s number of references
Deploy-Med Research to EMDR research in
dbase: the DoD‘s dbase is:‖
• CT – 647 • (a) 11
• CBT – 526 • (b) 50
• ET – 368 • (c) 158
• (d) 305
• VRT – 111
• Correct answer:
• CPT - 61
• None of the above
• ‗0‘ EMDR research!

Military PTSD Research

• Which of the • (a) Yoga
following therapies • (b) EMDR
is NOT one of the • (c) Acupuncture
13 current DoD
PTSD treatment • (d) Bioenergy
trials? • Answer:
• (b) EMDR

Restricted Access to EMDR Treatment
• Tricare Management Activity (TMA)
• 5 Feb 2005. ―I request that TRICARE coverage for this rapidly
emerging mainline therapy for PTSD be re-evaluated. I do not
believe that increased cost would result, as patients who are
candidates for EMDR are currently receiving traditional
psychotherapy. In fact, if the rapidity of response is as it appears
to be, costs would actually be reduced with shorter duration of
therapy.‖ (BG Dunn)
• 30 Jul 2007. ―I believe that increased costs should not result, as
patients who are candidates for EMDR are currently receiving
traditional psychotherapy and EMDR actually has shorter therapy
duration and better success. I strongly recommend that EMDR be
a TRICARE covered psychotherapy service for all TRICARE
beneficiaries.‖ (MAMC)
• 13 Aug 2008. ―Eye movement desensitization and reprocessing
therapy (EMDR) is considered an unproven treatment and is not
covered by TRICARE.‖ (OSD-HA/TMA)

Conclusions: Preventing the
Recycling of Trauma-Pension Wars
• Military medicine to take the lead and adopt a
holistic, neuropsychiatric paradigm of post war
disorders
• Top-down, aggressive public health campaign
to eliminate dualism, MH neglect and
disparity during times of war and peace
• Establish separate ‗Mental Health Corps‘ and
eliminate disparity between providers
• Eliminate harmful scientific resistance and
bias toward EMDR and any other future EBT

Carpe diem?

Slides: info@emdria.org
Contact Mark Russell: desensei01@aol.com

Meeting Military Mental Health Needs

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