The concept of PTSD has been developed with the evolution of warfare that goes way back to the ancient times, becoming an inevitable phenomenon during the American Civil War, affecting the soldiers. Since centuries, they have faced the brunt of innumerable traumatic incidents resulting from engaging in war and later, as prolonged psychological stress in the war veterans.

Military trauma is reported to result in higher levels of psychological distress than other traumatic events. Post-traumatic stress disorder (PTSD) is one possible consequence faced by the forces of all nations experiencing military traumas. PTSD has been defined as “the development of such characteristics and persistent symptoms, along with difficulty in functioning properly after exposure to a life-threatening experience or to an event that either involves a threat to life or serious injury.”  In addition to military combat, PTSD can result from the experience or witnessing a terrorist attack, violent crime or abuse, natural disasters, a serious accident, or exposure to vicious personal assaults. 

In this era of modern warfare, soldiers face various stress triggers, which include prolonged combat exposure, resulting in fear and sustained anticipatory anxiety, concerns about the biological or chemical weapons, and unpredictability about the duration of a single or multiple deployments. For many soldiers, these triggers contribute to the development of mental distress and psychiatric disorders, including PTSD.
When you serve in the military, you may be exposed to different types of traumas. The war you served in may also affect the risk of PTSD because of the types of traumas that are common. War zone deployment, training accidents and military sexual trauma may also lead to PTSD.
More than a decade of war in the Middle East has pushed PTSD to the forefront of public health concerns. The past several years have seen a dramatic increase in the number of war veterans seeking help for PTSD, shining a spotlight on this debilitating condition and raising critical questions about appropriate treatment options and barriers to care.
While PTSD extends far beyond the military, affecting millions of adults each year, the problem is particularly acute among the war veterans. Not only are the recent veterans at a higher risk of suffering from PTSD than the general population, they also face different barriers in accessing the adequate treatment. These include the requirement of either an honorable or general discharge, and the social stigma associated with mental illness within the military communities. 

In this era of modern warfare, soldiers face various stress triggers which include prolonged combat exposure, resulting in fear and sustained anticipatory anxiety, concerns about the biological or chemical weapons, and unpredictability about the duration of a single or multiple deployments. For many soldiers, these triggers contribute to the development of mental distress and psychiatric disorders, including PTSD.

The concept of war-induced psychological trauma likely goes back to warfare itself, with one of its first mentions by the Greek historian Herodotus. In writing about the Battle of Marathon in 490 B.C., Herodotus described an Athenian warrior who went permanently blind when the soldier standing next to him was killed, although the blinded soldier himself had not been wounded. Such accounts of psychological symptoms following the military trauma have been featured in the literature of many early cultures, and it is speculated that the ancient soldiers have experienced the stresses of war in much the same way as their modern-day counterparts.
The symptoms and syndrome of PTSD became increasingly evident during the American Civil War (1861-1865). Often referred to as the country’s bloodiest conflict, the Civil War saw the first widespread use of rapid-fire rifles, telescopic sights, and other innovations in weaponry that greatly increased destructiveness in battle and left those who survived with a myriad of physical and psychological injuries.
The Civil War also became the foundation of formal medical attempts to address the psychological effects of combat on the military veterans. Jacob Mendez Da Costa (1833-1900), a cardiologist and assistant surgeon in the United States Army, undertook a research on “irritable heart” (neurocirculatory asthenia) in soldiers, and during the Civil War. This PTSD-like disorder was referred to as “Da Costa’s syndrome.”  Da Costa reported in the American Journal of Medical Science that the disorder, marked by the shortness of breath, rapid pulse, and fatigue, is most commonly observed in soldiers during times of stress, especially when fear is involved.
Over the next century of American warfare, PTSD would be coined by many different names and diagnoses, including “shell shock” (World War I), “battle fatigue” (World War II), and “post-Vietnam syndrome.” An estimated 700,000 Vietnam veterans, almost 25% of those who served in the war, have required some form of psychological care due to the delayed effects of combat exposure. The diagnosis of PTSD was not adopted until the late 1970s, and it became official in 1980 with its inclusion in the third edition of the Diagnostic and Statistical Manual of Mental Disorders.

The Civil War also became the foundation of formal medical attempts to address the psychological effects of combat on the military veterans. Jacob Mendez Da Costa (1833-1900), a cardiologist and assistant surgeon in the United States Army, undertook a research on “irritable heart” (neurocirculatory asthenia) in soldiers, and during the Civil War. This PTSD-like disorder was referred to as “Da Costa’s syndrome.”  

The rates of PTSD and common mental disorders are higher amongst the veterans who were deployed to conflicts when compared with those who were not deployed, suggesting that deployment is a factor that increases the risk of mental disorders.  Active deployment is expected to increase the risk of exposure to a traumatic event and therefore subsequent mental health difficulties. Exposure to an intense combat and life-threatening situations are known combat-related risk factors for PTSD. These types of trauma events support a more traditional view that PTSD is developed from a fear-based trauma. However, more recent evidence demonstrates that PTSD encompasses many different emotions, for example, guilt, shame, anger, and not solely fear. This has led to changes in how PTSD is classified—the Diagnostic and Statistical Manual (DSM-5) removed PTSD from the anxiety disorder classification and placed it under its own category titled ‘Trauma and Stressor-related Disorders’.
PTSD can be either acute or chronic. The symptoms of acute PTSD last for at least one month but less than three months after the traumatic event. When faced with a stressful event, the body first mobilizes to deal with the danger. The fight-or-flight response is activated, which prepares people to defend themselves or flee the situation. It causes a cascade of physiological effects including increased heart rate, rapid breathing, dilated pupils, and increased muscle tension. In chronic PTSD, symptoms last for more than three months after an exposure to the trauma.
Soldiers' responses to the traumatic stress in a combat vary, but most responses occur in sequential phases. Immediate symptoms may include anxiety, confusion, fear or numbness. Delayed symptoms may include apathy, grief, intrusive thoughts or withdrawal. Most soldiers naturally adapt and recover normal functioning. However, acute stress disorder, which may precede PTSD, must be considered when this cluster of symptoms lasts up to four weeks and causes the patient clinically significant difficulties in proper functioning. A pathological response that persists beyond four weeks is called PTSD.

Veterans suffering from PTSD experience intense responses to stimuli, including flashbacks, anxiety, and combative or defensive behaviour. The intensity of this hyperarousal can cause veterans to avoid experiences that trigger such symptoms which make emotionally numb, detached, or withdrawn–all hallmarks of PTSD.

Chronic PTSD affects biological, psychological and behavioural processes, which can result in severe functional impairment, reduced quality of life, and high comorbidity with medical and other psychiatric disorders. Veterans suffering from PTSD experience intense responses to stimuli, including flashbacks, anxiety, and combative or defensive behaviour. The intensity of this hyperarousal can cause veterans to avoid experiences that trigger such symptoms which make them emotionally numb, detached, or withdrawn–all hallmarks of PTSD.
Because of the avoidance component of PTSD, patients often hesitate to seek care and may show up only after secondary medical or psychiatric problems have developed. In a primary care setting, these patients may complain of somatic symptoms such as generalized pain, fatigue, insomnia, migraines, or sexual dysfunction. Sources related to veterans must also be aware that other disorders such as depression, anxiety, or substance abuse may be the symptoms of underlying PTSD. Family members may provide clues supporting a picture of PTSD, including domestic violence, social withdrawal, or marital discord. Clinicians must further investigate these symptoms because the most effective management of PTSD relies on early and accurate detection.                                                                           
Several stressor types that do not constitute life-threatening situations have been found to correlate with PTSD such as witnessing atrocities, the loss of close friends and the act of killing. Carrying out a traumatic act, such as killing in combat, has also been identified as equally psychologically damaging when compared to being subjected to the trauma. Clinicians began to notice that engaging in killing had a psychological impact on the veteran population as early as the 1970s.
Despite being trained to kill, evidence suggests that the act of killing in combat can cause significant psychological distress. Some of the intricacies present in the psychological distress of combat veterans have been concluded as psychological distress, which occurs due to an internal conflict that arises when actions transgress the deeply held moral beliefs. 
Essentially, the event violates the moral beliefs and expectations that the person has. This is often referred to in the literature as a moral injury and it asserts that inner conflict often leads to the feelings of guilt and shame including suicide risk in a help-seeking veteran population. The resulting shame is accounted entirely for the effects of PTSD on suicidal ideation. 
The psychological distress caused by PTSD can have a long-term impact on veterans and cause difficulties when adjusting back to civilian life. Individuals with military-related PTSD have been shown to have a higher tendency for isolation, less social inclusion, and heightened aggression. Reported difficulties with social functioning, productivity, community involvement and self-care are many of the identified difficulties which lie outside the traditional role of healthcare, therefore highlighting the need for professionals to be trained specifically to work with the complexities present in this population.

A century after “the war to end all wars,” we continue to find our human community divided by conflict, affecting the military service members at large. The ghostly scars of PTSD have haunted generations of soldiers as well as the civilian survivors who have faced many types of traumas since long before the Great War. 

Studies have shown that while deployment increases the risk of PTSD, there are protective post-traumatic factors as well. In a study of U.S.’ active-duty military personnel, PTSD symptoms were less likely to occur when support was received from the individual, family or community sources. Specifically, self-efficacy, family coping, spouse/partner support, financial resources and religious participation, all moderated the relationship between stressful deployment experiences and PTSD symptoms. It is important to note that not all ex-serving personnel will struggle with PTSD.
A number of factors have been shown to increase the risk of PTSD in the veteran population, including younger age at the time of the trauma, racial minority status, lower socioeconomic status, lower military rank, lower education, higher number of deployments, longer deployments, prior psychological problems, and lack of social support from family, friends, and community. PTSD is also strongly associated with generalized physical and cognitive health symptoms attributed to mild traumatic brain injury.
After the threat has passed, the relaxation response helps return the body to its previous state of equilibrium. People with PTSD, however, are unable to fully leave the state of heightened awareness and readiness, which results in a variety of symptoms. Symptoms that may emerge after a traumatic experience include: avoidance behaviours, difficulty in concentrating, dissociation, heightened startle response, intrusive and negative thoughts, impulsive moods, and sleep problems including upsetting dreams.
The actual prevalence and incidence of PTSD in war veterans is difficult to establish. Differences in sampling and measurement strategies, diagnostic criteria, latency of assessment, and the possibility of recall bias leads to varying prevalence assessments. Associated comorbidities, symptom overlap with other psychiatric disorders, and cultural or socio-political factors may also influence the accuracy of the findings. Many of these epidemiologic studies are able to identify the risk factors behind PTSD development. The strongest association was between cumulative combat experience and probable PTSD risk. Specific exposures, such as intensity of urban combat, personal injury, witnessing others as wounded or killed, and prolonged or multiple tours, are predictive for PTSD development. 
While many important advancements have been made over the past few decades in understanding and treating the symptoms of PTSD, the rising number of PTSD cases continues to be a serious national public health concern. Cognitive behavioral therapy is a widely accepted method of treatment for PTSD, but there is clearly an urgent need to identify more effective pharmacological approaches for the management of PTSD symptoms, as not all patients will respond adequately to psychotherapy or evidence-based/first-line pharmacotherapy. Moreover, understanding of the underlying physiological and neurological processes will also be helpful in developing new and effective therapies to treat PTSD.
When active-duty soldiers experience the symptoms of PTSD, comprehensive mental health services are provided through the modern healthcare system. However, many patients are not identified or are inadequately treated before returning to civilian life. These veterans may be experiencing symptoms of an underlying PTSD. Further opportunities to develop new and innovative ways to overcome barriers to treating veterans with PTSD is also important. It is significant that they receive proper education, training, and tools to improve their understanding and develop skills for addressing the needs of this unique population.
A century after “the war to end all wars,” we continue to find our human community divided by conflict, affecting the military service members at large. The ghostly scars of PTSD have haunted generations of soldiers as well as the civilian survivors who have faced many types of traumas since long before the Great War. Despite the current societal acceptance of PTSD as a disorder worthy of compassion, diagnostic recognition, and multidisciplinary research, these scars have remained like ghosts, largely and frustratingly invisible in the sense that little is understood of their cellular basis in the human brain.
Our military involvements have raised awareness about the individual mental health consequences, such as PTSD that can arise from traumatic stress exposure during the course of military deployment. At the same time, the scientific and non-specialist general communities have become more attuned to the family issues that surround a veteran when he/she returns with PTSD, as well as the individual and familial effects that are likely and reciprocally related to the veteran's trauma recovery.

The writer is a professor, Fellow of the Royal College of Psychiatrists London, Fellow and Diplomate of the American Board of Psychotherapy, and Certified Counterintelligence Threat Analyst. He is currently a consultant forensic psychiatrist in the UK and Shifa International Hospital, Islamabad.
E-mail: [email protected]