April 24, 2007: Combat fatigue (or PTSD, post-traumatic stress disorder) is nothing new, but better diagnostic tools, plus political and media exploitation, are making it a lot more visible. This has resulted in better methods for dealing with it. But this has uncovered two particularly vexing problems. First, only about a third of the troops with PTSD will seek treatment. Second, research, and practical experience, has shown that the best time to deal with PTSD is as soon as it shows up. That spotlights another problem, that PTSD usually first manifests itself while troops are still in the combat zone, if not in combat itself. This has meant stationing lots of mental health personnel as close to the fighting as possible. Getting troops to acknowledge that PTSD is just another combat injury has proved difficult. But there is progress, albeit slow, in getting the troops to report problems they are having.

PTSD was first noted after the American Civil War. That war was one of the first to expose large numbers of troops to extended periods of combat stress. The symptoms, as reported in the press a century and a half ago, were not much different from what you hear today. At the time, affected veterans were diagnosed as suffering from "Irritable Heart" or "Nostalgia." Symptoms noted included fatigue, shortness of breath, palpitations, headache, excessive sweating, dizziness, disturbed sleep, fainting and flashbacks to traumatic combat situations. Many of these symptoms were noted while troops were still in uniform. And if enough troops in a unit were showing the symptoms, the unit was described as "shaken," and not all that ready for combat.

In World War I, the condition was called "Shell Shock," and the symptoms were the same, although there was more attention paid to vets who jumped and got very nervous when they heard loud noises. Again, the symptoms were noted among troops still in the trenches. But many senior commanders thought shell shocked soldiers who refused to fight were cowards or shirkers. Many of these men were shot for refusing to fight. But many medical officers saw what was really going on, and began developing ways to diagnose and treat PTSD.

In World War II and Korea the condition was called "Combat Stress Reaction." Same symptoms. After Vietnam, the term "Post-Traumatic Stress Syndrome" became popular, until it evolved into PTSD. It was during World War II that researchers began compiling lots of data on troops so affected. It was discovered that most troops were likely to develop debilitating PTSD after about 200 days of combat (that is, the stress of having your life threatened by enemy fire).

Israel noted an interesting angle to PTSD after the 1982 war in Lebanon. This conflict went on longer than previous wars, and used a larger number of older reserve troops. The older soldiers, especially reservists, tended to be more prone to coming down with PTSD. This was probably due to the fact the full time soldiers are constantly conditioned to deal with stress. While this is often referred, often derisively, as "military discipline," it has been known for thousands of years that such practices reduce stress and panic during combat. Apparently it reduces the chances of coming down with PTSD as well. Israelis also began intensive research into PTSD around the same time, and have led the field ever since.

There been a lot of progress in developing treatments for PTSD. The Germans and the British were very effective in their treatment of PTSD during World War II , and the U.S. adopted many of those techniques (recognize the condition for what it is, and treat the troops quickly and close to the front) after the war. The Germans and Brits were ahead of the US because of extensive experience with PTSD during World War I.

PTSD prevention is one reason U.S. and British troops live so well in a combat zone (air conditioned sleeping quarters, good food, fast medical care, lots of amenities). This has probably extended the PTSD limit to 300 (or more) combat days. But U.S. troops can now accumulate that much action in two or three twelve month tours in Iraq or Afghanistan. The beg issue now is getting troops to recognize PTSD as just another combat injury, and to get it treated as soon as possible, before it gets worse, or causes permanent damage. This campaign is making progress, but it's slow going. Mental illness scares people, always has, probably always will. But the troops in a combat zone tend to be mercilessly practical. If you don't fix things that break, that lapse can get you killed.

Currently, about 400 soldiers a year are sent home from Iraq because of severe PTSD, and thousands have less serious bouts of PTSD, which are treated in Iraq, with the soldier soon returning to duty. There has not been any surge in PTSD injuries, and the stats seem to show that efforts to deal with PTSD quickly, and on the spot, are having an impact.